The interrater reliability of a Dutch version of the Structured Clinical Interview for DSM-III-R Personality Disorders

Self-selection biases in psychological studies: Personality and affective disorders are prevalent among participants

Respondents select the type of psychological studies that they want to participate in consistence with their needs and individual characteristics, which creates an unintentional self-selection bias. The question remains whether participants attracted by psychological studies may have more psychological dysfunctions related to personality and affective disorders compared to the general population. We investigated (N = 947; 62% women) whether the type of the invitation (to talk about recent critical or regular life events) or the source of the data (either face-to-face or online) attracts people with different psychopathology. Most importantly, participants who alone applied to take part in paid psychological studies had more symptoms of personality disorders than those who had never before applied to take part in psychological studies. The current results strongly translate into a recommendation for either the modification of recruitment strategies or much greater caution when generalizing results for this methodological reason.

What is at the core of OCD? A network analysis of selected obsessive-compulsive symptoms and beliefs

BACKGROUND

Obsessive-compulsive disorder (OCD) is a heterogeneous condition that consists of distinct subtypes, and identification of its core symptoms may inform how to best conceptualize the heterogeneity. Accordingly, we used network analysis to evaluate which symptoms (and associations between symptoms) are most central to OCD symptoms and beliefs.

METHODS

Participants consisted of a combined sample of adults with a primary diagnosis of OCD (N = 150), those with other primary diagnoses (N = 114), and an unselected nonclinical sample (N = 310). Network analysis was used to identify the most central symptoms (nodes) and associations between symptoms (edges) assessed by the Obsessive-Compulsive Inventory-Revised and the Obsessional Beliefs Questionnaire-44.

RESULTS

The most central symptoms in the network were negative appraisals of intrusive thoughts (i.e., Having intrusive thoughts means I'm out of control). Some of the strongest associations between symptoms were also observed for those pertaining to intrusive thoughts and their negative appraisal. Furthermore, central symptoms in the network predicted depression and anxiety (over and above peripheral symptoms) among those with a primary diagnosis of OCD, but not the severity of OCD symptoms.

LIMITATIONS

The approach was exploratory rather than experimental and relied solely on self-report measures of OCD symptoms and beliefs.

CONCLUSIONS

Negative appraisals of intrusive thoughts were the most central symptoms in the OCD network, and they uniquely predict co-occurring symptoms of anxiety and depression, suggesting that these symptoms should be prioritized in theoretical and treatment models of OCD.

Early Trauma Inventory Self-Report Short Form (ETISR-SF): validation of the Swedish translation in clinical and non-clinical samples

PURPOSE

Childhood trauma in an important public health concern, and there is a need for brief and easily administered assessment tools. The Early Trauma Inventory (ETI) is one such instrument. The aim of this paper is to test the psychometric properties of the Swedish translation of the short, self-rated version (ETISR-SF), and to further validate the instrument.

MATERIALS AND METHODS

In this cross-sectional study, 243 psychiatric patients from an open care unit in Sweden and 56 controls were recruited. Participants were interviewed and thereafter completed the ETISR-SF. Internal consistency was calculated using Cronbach's alpha, a confirmatory factor analysis (CFA) was performed and goodness-of-fit was determined. Intra Class Correlation (ICC) was used to calculate test-retest reliability. Discriminant validity between groups was gauged using the Mann-Whitney U-test.

RESULTS

Cronbach's alpha varied between 0.55 and 0.76, with higher values in clinical samples than in controls. Of the four domains, general trauma showed a lower alpha than the other domains. The CFA confirmed the four-factor model previously seen and showed good to acceptable fit. The ICC value was 0.93, indicating good test-retest reliability. According to the Mann-Whitney U-test, the non-clinical sample differed significantly from the clinical sample, as did those with PTSD or borderline diagnosis from those without these diagnoses.

CONCLUSIONS

The Swedish translation of the ETISR-SF was found to have similar psychometric properties as both the original version and translations. ETISR-SF scores could also distinguish between different diagnostic groups associated with various degrees of trauma, which supports its discriminant validity.

Continuity Between DSM-5 Section II and III Personality Disorders in a Dutch Clinical Sample

The goal of this study was to evaluate the continuity across the Section II personality disorders (PDs) and the proposed Section III model of PDs in the Diagnostic and Statistical Manual of Mental Disorders (5th ed. [DSM-5]; American Psychiatric Association, 2013a ). More specifically, we analyzed association between the DSM-5 Section III pathological trait facets and Section II PDs among 110 Dutch adults (M age = 35.8 years, range = 19-60 years) receiving mental health care. We administered the Structured Clinical Interview for DSM-IV Axis II Disorders to all participants. Participants also completed the self-report Personality Inventory for DSM-5 (PID-5) as a measure of pathological trait facets. The distributions underlying the dependent variable were modeled as criterion counts, using negative binomial regression. The results provided some support for the validity of the PID-5 and the DSM-5 Section III Alternative Model, although analyses did not show a perfect match. Both at the trait level and the domain level, analyses showed mixed evidence of significant relationships between the PID-5 trait facets and domains with the traditional DSM-IV PDs.

Treating substance abuse is not enough: comorbidities in consecutively admitted female prisoners

INTRODUCTION

Several studies have pointed to high rates of substance use disorders among female prisoners. The present study aimed to assess comorbidities of substance use disorders with other mental disorders in female prisoners at admission to a penal justice system.

METHODS

A sample of 150 female prisoners, consecutively admitted to the penal justice system of Berlin, Germany, was interviewed using the Mini-International Neuropsychiatric Interview (MINI). The presence of borderline personality disorder was assessed using the Structured Clinical Interview II for DSM-IV. Prevalence rates and comorbidities were calculated as percentage values and 95% confidence intervals (CIs).

RESULTS

Ninety-three prisoners (62%; 95% CI: 54-70) had substance use disorders; n=49 (33%; 95% CI: 24-42) had alcohol abuse/dependence; n=76 (51%; 95% CI: 43-59) had illicit drug abuse/dependence; and n=53 (35%; 95% CI: 28-44) had opiate use disorders. In the group of inmates with substance use disorders, 84 (90%) had at least one other mental disorder; n=63 (68%) had comorbid affective disorders; n=45 (49%) had borderline or antisocial personality disorders; and n=41 (44%) had comorbid anxiety disorders.

CONCLUSIONS

Female prisoners with addiction have high rates of comorbid mental disorders at admission to the penal justice system, ranging from affective to personality and anxiety disorders. Generic and robust interventions that can address different comorbid mental health problems in a flexible manner may be required to tackle widespread addiction and improve mental health of female prisoners.

A comparison of Cohen's Kappa and Gwet's AC1 when calculating inter-rater reliability coefficients: a study conducted with personality disorder samples

Background

Rater agreement is important in clinical research, and Cohen’s Kappa is a widely used method for assessing inter-rater reliability; however, there are well documented statistical problems associated with the measure. In order to assess its utility, we evaluated it against Gwet’s AC1 and compared the results.

Methods

This study was carried out across 67 patients (56% males) aged 18 to 67, with a mean SD of 44.13 ± 12.68 years. Nine raters (7 psychiatrists, a psychiatry resident and a social worker) participated as interviewers, either for the first or the second interviews, which were held 4 to 6 weeks apart. The interviews were held in order to establish a personality disorder (PD) diagnosis using DSM-IV criteria. Cohen’s Kappa and Gwet’s AC1 were used and the level of agreement between raters was assessed in terms of a simple categorical diagnosis (i.e., the presence or absence of a disorder). Data were also compared with a previous analysis in order to evaluate the effects of trait prevalence.

Results

Gwet’s AC1 was shown to have higher inter-rater reliability coefficients for all the PD criteria, ranging from .752 to 1.000, whereas Cohen’s Kappa ranged from 0 to 1.00. Cohen’s Kappa values were high and close to the percentage of agreement when the prevalence was high, whereas Gwet’s AC1 values appeared not to change much with a change in prevalence, but remained close to the percentage of agreement. For example a Schizoid sample revealed a mean Cohen’s Kappa of .726 and a Gwet’s AC1of .853 , which fell within the different level of agreement according to criteria developed by Landis and Koch, and Altman and Fleiss.

Conclusions

Based on the different formulae used to calculate the level of chance-corrected agreement, Gwet’s AC1 was shown to provide a more stable inter-rater reliability coefficient than Cohen’s Kappa. It was also found to be less affected by prevalence and marginal probability than that of Cohen’s Kappa, and therefore should be considered for use with inter-rater reliability analysis.

DSM-IV and ICD-10 personality disorders: a comparison of a self-report questionnaire (DIP-Q) with a structured interview

OBJECTIVE

Diagnosing personality disorders according to structured expert interviews is time-consuming and costly. For epidemiological studies, self-report instruments have several advantages. The DSM-IV and ICD-10 personality questionnaire (DIP-Q) is a selfreport questionnaire constructed to identify personality disorder according to DSM-IV and ICD-10.

METHOD

The DIP-Q is validated vs a structured expert interview in a clinical sample of 138 individuals. In addition, prevalence rates yielded by DIP-Q among 136 healthy volunteers are assessed and compared to expected prevalence.

RESULTS

For DSM-IV the agreement for any personality disorder as measured by Cohen's Kappa was 0.61 and 0.56 for ICD-10. Overall sensitivity for any personality disorder was for DSM-IV 0.84 and for ICD-10 0.85. However, specificity was lower: 0.77 and 0.70, respectively. When dimensional scores between self-report and interview for each personality disorder were compared, the intraclass correlation for the DSMIV entities was 0.37-0.87 and for the ICD-10 entities 0.33-0.73. Among healthy volunteers the base rate of personality disorders was found to be 14%.

CONCLUSION

DIP-Q can be used as a screening instrument for personality disorders according to DSM-IV and ICD-10. Self-report questionnaires such as DIP-Q will probably play an increasingly important role in future epidemiological studies.

The effect of trauma onset and frequency on PTSD-associated symptoms

BACKGROUND

Different trauma characteristics have been suggested to lead to distinct symptom profiles. This study investigates the effect of two trauma characteristics, age of onset and frequency, on PTSD symptom profiles.

METHODS

Trauma characteristics (childhood versus adulthood trauma and single versus multiple trauma), psychiatric diagnosis, PTSD severity, depressive symptoms, dissociation, guilt, shame, anger, and interpersonal sensitivity were assessed in 110 PTSD outpatients.

RESULTS

Single versus multiple trauma and childhood versus adulthood trauma groups did not differ in depressive symptom and co-morbidity. Multiple trauma patients reported more dissociation, guilt, shame, and interpersonal sensitivity than those that experienced single trauma. Anger of multiple trauma patients was more often directed towards themselves, whereas anger in single trauma patients was more often directed towards others. Childhood trauma patients reported more dissociation and state anger than adulthood trauma patients. However, with the exception of multiple trauma patients having more dissociation and shame than those with single trauma, all differences disappeared after controlling for PTSD severity.

LIMITATIONS

This study is a first step in unraveling the impact of different trauma characteristics. Causal inferences are limited, though, because of the cross-sectional design.

CONCLUSIONS

The results suggest that experiencing trauma at young age or multiple times may lead to different symptom profiles but these are, with the exception of dissociation and shame, dependent on PTSD severity. These results support the proposed DSM-V criteria in which these symptoms appear as part of the disorder, and stress the importance of early treatment.

Stepped care versus standard cognitive-behavioral therapy for obsessive-compulsive disorder: a preliminary study of efficacy and costs

BACKGROUND

Exposure and response prevention (ERP) for obsessive-compulsive disorder (OCD) is underutilized, in part because of costs and time requirements. This study extends pilot work investigating the use of a stepped care ERP administration, in which patients are first given a low-intensity, low-cost treatment and the more costly intervention is reserved for those who do not respond to the first intervention.

METHODS

Thirty adults with OCD were randomized to receive stepped care ERP or standard ERP. Those receiving stepped care started with three sessions over 6 weeks of low-intensity counseling with ERP bibliotherapy; patients failing to meet strict responder criteria after 6 weeks were given the more traditional treatment of therapist-administered ERP (17 sessions twice weekly). Those receiving standard ERP received the therapist-administered ERP with no lower-intensity lead-in.

RESULTS

The two treatments were equally efficacious, with 67% of stepped care completers and 50% of standard treatment completers meeting criteria for clinically significant change at posttreatment. Similarly, no differences in client satisfaction ratings were obtained between the two groups. Examination of treatment costs, however, revealed that stepped care resulted in significantly lower costs to patients and third-party payers than did standard ERP, with large effect sizes.

CONCLUSIONS

These results suggest that stepped care ERP can significantly reduce treatment costs, without evidence of diminished treatment efficacy or patient satisfaction. Additional research is needed to determine the long-term efficacy and costs of stepped care for OCD, and to examine the financial and therapeutic impact of implementing stepped care in community settings.

Dependent personality traits and information processing: Assessing the interpretation of ambiguous information using the Thematic Apperception Test

OBJECTIVES

This study was designed to investigate interpretation bias in people with dependent personality traits.

METHOD

Eight Thematic Apperception Test (TAT) cards were administered to participants (N=56) who scored high or low on DSM-III-R dependent personality pathology. Two independent judges rated the TAT stories using a rating list based on the cognitive model of the dependent and paranoid personality disorder.

RESULTS

Controlling for self-esteem, the dependent interpretation bias appeared to be specific for dependent personality pathology. SEM analysis supported a mediation model in which beliefs mediate the relationship between DSM-III-R traits and interpretation bias.

CONCLUSIONS

The findings in this study support the hypothesis that people with dependent traits are characterized by a schema-related interpretation bias and that this bias is mediated by dependent beliefs.

[Psychiatric disorders among parents of patients with anorexia nervosa and bulimia nervosa]

Family diseases represent a risk factor in the multifactorial etiology model regarding the genesis of eating disorders. In German-speaking countries only a few studies give attention to this topic. The aim of this study is to investigate the occurrence frequency of psychiatric disorders and personality styles among parents of juvenile patients with eating disorders. Furthermore a comparison between parents of patients with restrictive anorexia nervosa (AN-R) and parents of patients with bulimia nervosa (BN) is carried out. Psychiatric disorders listed on Axis I and Axis II of DSM-IV (American Psychiatric Association (APA), 1994) and personality styles were assessed in 73 mothers and fathers of 27 patients with AN-R and 13 patients with BN. The results show a high psychiatric strain among parents of patients with AN-R and BN. However the overall psychiatric strain does not differ among the parents of patients with AN-R and BN. Depressive disorders were more frequently observed among mothers of patients with AN-R. Parents of patients with BN showed higher occurrences of paranoid and schizotypal personality styles. A vulnerability of psychiatric disorders is indicated among parents of patients with eating disorders in general but nonspecific for AN-R or BN.

Persönlichkeitsstörungen bei jugendlichen Patientinnen mit Anorexia und Bulimia nervosa

Zielsetzung: Ziel der vorliegenden Untersuchung war es, das Auftreten von Persönlichkeitsstörungen bei jugendlichen Patientinnen mit Anorexia (AN) und Bulimia nervosa (BN) anhand des Strukturierten Klinischen Interviews für DSM-IV (SKID-II) zu überprüfen. Methodik: 99 konsekutiv erfasste Patientinnen (MAlter = 16.3 ± 1.6) wurden mittels SKID-II im Hinblick auf PS untersucht. Des Weiteren wurde der Einfluss von Alter, Achse-I-Komorbiditäten und Behandlungsart auf die Ausbildung einer PS getestet. Ergebnisse: 30.3 % der untersuchten Patientinnen erhielten nach SKID-II die Diagnose einer Persönlichkeitsstörung (PS). Patientinnen mit einer AN-binge-purging Typus wiesen gegenüber den beiden anderen Essstörungsgruppen eine höhere Prävalenzrate bezüglich Persönlichkeitsstörungen und ebenso höhere Werte der dimensionalen Scores auf. Zudem zeigen unsere Ergebnisse, dass Alter und Achse-I-Komorbiditäten mit der Entwicklung von Persönlichkeitsstörungen assoziiert sind. Schlussfolgerung: Zwischen den drei Essstörungsgruppen bestehen deutliche Unterschiede hinsichtlich des Auftretens von Persönlichkeitsstörungen. Patientinnen mit einer AN-binge-purging Typus sind stärker betroffen als Patientinnen mit einer BN oder restriktiven AN. Dies und ebenso der Einfluss von Alter und Achse-I-Komorbiditäten sollten bei der Therapie von Essstörungspatientinnen berücksichtigt werden.

Group cognitive and behavioral treatment for compulsive hoarding: a preliminary trial

BACKGROUND

Time-limited group cognitive behavioral treatments (GCBT) for obsessive-compulsive disorder have demonstrated improvement in target symptoms. One small sample study of GCBT specifically for hoarding problems also showed benefit. This study examines the efficacy of a specialized GCBT for compulsive hoarding on a larger sample.

METHODS

Thirty-two clients diagnosed with hoarding participated in five groups. Four groups met once weekly for 2 hour over 16 weeks (n=27) and one group met for 20 weeks (n=5). All participants had two individual 90-min home sessions. Self-report assessments were completed at baseline, mid-treatment, and post-treatment about hoarding behavior and related symptoms (e.g., depression). The sample was predominantly female, White, highly educated, unemployed, and not partnered/married; mean age was 53. A majority was diagnosed with major depressive disorder and obsessive-compulsive personality disorder.

RESULTS

Participants showed significant improvement from pre- to post-treatment on the Saving Inventory Revised, Saving Cognitions Inventory, Clutter Image Rating, and Clinical Global Severity. The most recent group (n=8) that used a more formalized treatment and research protocol improved significantly more than did earlier members.

CONCLUSION

This study demonstrates the feasibility and modest success of GCBT methods in improving hoarding symptoms. Group treatment may be especially valuable because of its cost-effectiveness, greater client access to trained clinicians, and reduction in social isolation and stigma linked to this problem. Further research is needed to improve the efficacy of GCBT methods for hoarding and to examine durability of change, predictors of outcomes, and processes that influence change.

Diagnostik von Persönlichkeitsstörungen im Jugendalter nach SKID-II

Zusammenfassung: Fragestellung: Ziel der vorliegenden Untersuchung war eine Überprüfung der Anwendbarkeit des Strukturierten Klinischen Interviews für DSM-IV, Achse II: Persönlichkeitsstörungen (SKID-II) im Jugendalter sowie eine Untersuchung zur Übereinstimmung zwischen SKID-II Diagnosen und klinischem Urteil. Zusätzlich wurde der Frage nachgegangen, welche Faktoren bei Patientinnen einer jugendpsychiatrischen Inanspruchnahmepopulation Persönlichkeitsstörungen (PS) prognostizieren. Methodik: Insgesamt wurden 110 stationär behandelte, jugendpsychiatrische Patienten im Alter von 14-18 Jahren mit dem SKID-II und dem Persönlichkeitsstil- und Störungsinventar (PSSI) untersucht. Ergebnisse: 32.7% der untersuchten Patienten zeigten nach SKID-II die Diagnose einer PS. Die Übereinstimmung zwischen kategorialem Urteil (PS liegt vor versus PS liegt nicht vor) des SKID-II und der klinischen Diagnose erwies sich insgesamt als niedrig. Lediglich für die histrionische PS und für die Borderline-PS ergaben sich annehmbare bis sehr gute Übereinstimmungen. Logistische Regressionsanalysen identifizierten «Anorexia nervosa (bulimisch)», «einfache Aktivitäts- und Aufmerksamkeitsstörung/Störung des Sozialverhaltens (ADHD/SSV)» und «Schicht» als relevante prognostische Faktoren für PS. Schlussfolgerungen: Das SKID-II, das primär für Erwachsene entwickelt wurde, ist für den Gebrauch bei Jugendlichen gut einsetzbar. Im jugendpsychiatrischen Bereich sind die Diagnosen Anorexia nervosa (bulimisch) und ADHD/SSV eng mit der Entwicklung einer PS assoziiert.

The interrater reliability of the Structured Interview for DSM-IV Personality

We examined the joint interview interrater reliability of the Structured Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Personality Disorders (SIDP-IV) in 433 non-treatment-seeking military recruits. Reliability was computed for the diagnosis of a specific personality disorder (PD) and for the number of PD criteria present, and computed using a dimensional score. Reliability increased when PDs were computed using dimensional scores rather than categorical scores. Avoidant and dependent PDs demonstrated the highest interrater reliability, whereas schizoid and schizotypal showed the lowest. This large sample allowed us to perform item-level analyses of the SIDP-IV. Interrater reliability for each of the PD criteria was generally more than 0.70, with the notable exception of criteria scored through observation only. Overall, the SIDP-IV demonstrated good reliability in a non-treatment-seeking population.

Influences of beliefs and personality disorders on treatment outcome in anxiety patients

The present study investigated the effects of personality disorders (PDs) and specific PD-related beliefs on the results of (cognitive-)behavioral therapy for anxiety disorders in a sample of 398 outpatients. The authors used a prospective design in which relationships between PD variables before treatment and outcome measures at posttest and follow-up were evaluated with multilevel analyses. People with PDs and PD-related beliefs reported higher symptom levels at outcome. However, these effects were not as strong as might be expected on the basis of prevailing clinical thought in this area. Dropout rates were not influenced by the presence of 1 or more PDs or PD-related beliefs. Results indicate that treatment of anxiety disorders in patients with concomitant one or more PDs is appropriate.

Beliefs in personality disorders: a test with the Personality Disorder Belief Questionnaire

The hypothesis that each personality disorder (PD) is characterized by a specific set of beliefs was tested in a sample of 643 subjects, including non-patient controls, axis-I and axis-II patients, diagnosed with SCID-I and -II interviews. Beliefs of six PDs (avoidant, dependent, obsessive-compulsive, paranoid, histrionic, borderline) were assessed with the Personality Disorder Belief Questionnaire (PDBQ). Factor analyses supported the existence of six hypothesized sets of beliefs. Structural equation modeling (SEM) supported the hypothesis that each PD is characterized by a specific set of beliefs. Path coefficients were however in the medium range, suggesting that PDs are not solely determined by beliefs. Nevertheless, empirically derived cutoff scores of the six belief subscales were reasonably successful in classifying subjects, percentages ranging form 51% to 83%. It appeared that there was a monotonical increase in scores on each belief subscale from non-patient controls, to patients without any PD, to patients with PDs (other than the pertinent PD), to patients with the pertinent PD. This suggests that PD-related beliefs are at least partly associated with (personality) psychopathology in general. Another explanation is that many patients' position on the underlying dimensions is not high enough to lead to a DSM PD diagnosis, but high enough to lead to an elevated belief score.

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.

A double blind comparison of venlafaxine and paroxetine in obsessive-compulsive disorder

While the usefulness of clomipramine and selective serotonin reuptake inhibitors (SSRIs) in obsessive-compulsive disorder (OCD) has been established, the efficacy of serotonin-norepinephrine reuptake inhibitors remains to be determined. This report describes the first randomized double-blind comparison study of an SNRI in patients with obsessive-compulsive disorder. The current study compares the efficacy and tolerability of venlafaxine with paroxetine. One hundred and fifty patients with primary OCD according to DSM-IV criteria were randomly assigned in a 12-week double-blind trial to receive dosages titrated upward to 300 mg/d of venlafaxine (n = 75) or 60 mg/d of paroxetine (n = 75). Primary efficacy was assessed by the change from baseline on the Yale-Brown obsessive-compulsive scale (Y-BOCS). Other assessments throughout the trial included the Hamilton depression rating scale, and the Hamilton anxiety rating scale. An intent-to-treat, last-observation-carried-forward analysis demonstrated a mean decrease on the Y-BOCS of 7.2 +/- 7.5 in the venlafaxine group and of 7.8 +/- 5.4 in the paroxetine group. In both treatment groups, a responder rate (decrease > 35% on the Y-BOCS) of approximately 40% was found. There were no significant differences between venlafaxine and paroxetine with regard to response or responder rates. The incidence of adverse events for venlafaxine and paroxetine was comparable. The most common side effects for venlafaxine were somnolence, insomnia, a dry mouth, and sweating; and for paroxetine somnolence, sweating, nausea, and headache. These results show that venlafaxine was equally effective to paroxetine in treating patients with OCD. Venlafaxine may be a useful therapy for obsessive-compulsive patients, but is not superior to SSRIs.

Assessment of DSM-IV personality disorders in obsessive-compulsive disorder: comparison of clinical diagnosis, self-report questionnaire, and semi-structured interview

In patients with obsessive-compulsive disorder, personality disorders are not many times assessed according to DSM-IV criteria. The purpose of the present study is to examine the prevalence of personality disorders diagnosed according to the DSM-IV in a severely disordered OCD population (n=65) with three different methods of assessing personality disorders (structured interview, questionnaire, and clinical diagnoses). Furthermore, correspondence between these different methods was investigated and their construct validity was examined by relating the three methods to external variables. Each method resulted in a predominance of Cluster C personality disorders, and obsessive-compulsive personality disorder had the highest prevalence. However, there was generally low correspondence regarding which patient had which personality disorder. Results concerning the relation of external variables were the most promising for the structured clinical interview.

Short-interval test-retest interrater reliability of the Dutch version of the Structured Clinical Interview for DSM-IV personality disorders (SCID-II)

This study examined the short-interval test-retest reliability of the Structured Clinical Interview (SCID-II: First, Spitzer, Gibbon, & Williams, 1995) for DSM-IV personality disorders (PDs). The SCID-II was administered to 69 in- and outpatients on two occasions separated by 1 to 6 weeks. The interviews were conducted at three sites by ten raters. Each rater acted as first and as second rater and equal number of times. The test-retest interrater reliability for the presence or absence of any PD was fair to good (kappa = .63) and was higher than values found in previous short-interval test-retest studies with the SCID-II for DSM-III-R. Test-retest reliability coefficients for trait and sumscores were sufficient, except for dependent PD. Values for single criteria were variable, ranging from poor to good agreement. Further large-scale test-retest research is needed to test the interrater reliability of more categorical diagnoses and single traits.

A score for predicting response to pharmacotherapy in obsessive-compulsive disorder

Although there have been many attempts to find predictors of therapeutic response to antidepressant treatment of obsessive-compulsive disorder (OCD), few reports have evaluated the joint predictive value of a number of clinical characteristics. This study aimed to identify clinical predictors of outcome in OCD, and to develop an easily applicable method to predict response to drug treatment. One hundred and fifty patients with primary OCD according to DSM-IV criteria were randomly assigned in a 12-week, double-blind, comparison trial with a selective serotonin reuptake inhibitor (paroxetine), and a serotonin-noradrenaline reuptake inhibitor (venlafaxine). The primary efficacy parameter was the Yale-Brown obsessive-compulsive scale (Y-BOCS) score, and response to treatment was prospectively defined as a >/= 35% decrease from the beginning. A stepwise multivariate analysis was used to identify predictors. The absence of previous therapies, moderate baseline severity of obsessive-compulsive symptoms (Y-BOCS score < 23), and low Hamilton Depressive Rating Scale scores (6-15) were found to be prognostic determinants of good response to pharmacotherapy. The prognostic ability of the prediction model to discriminate between responders and non-responders was quantified as the area under the receiver operating/operator characteristic curve (ROC area), which was 0.71 (95% confidence interval 0.63-0.8), demonstrating a reasonable discriminatory power. This study is the first to present a model that can estimate by the use of prediction rules the probability of treatment response to antidepressants in patients with OCD.

Twelve month test-retest reliability of a Japanese version of the Structured Clinical Interview for DSM-IV Personality Disorders

The purpose of the present study was to examine the long-interval test-retest reliability of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (4th edn; DSM-IV) Axis II Personality Disorders (SCID-II) Japanese version. One hundred and twenty outpatients with anxiety disorders completed the self-report SCID-II personality questionnaire (SCID-II-PQ) and structured interviews, and then again 12 months later. In the SCID-II-PQ, 70.8% and 71.7% of the patients had a personality disorder (PD) at the first evaluation and second evaluation 12 months later, respectively, and Cohen's kappas ranged from 0.29 for paranoid PD to 0.83 for histrionic PD, and overall kappa was 0.56. In the SCID-II interviews, 47.5% and 41.7% of the patients fulfilled the criteria for PD at the first and the second evaluations, respectively. At least one PD was identified in 49 subjects (40.8%), of whom 65.3% had one PD, 30.6% had two PD, 2% had three PD, and 2% had four PD; the most frequently diagnosed PD were from cluster C (60.9%). The overall base rate of 12 PD was 7%, and overall kappa was 0.87. Cohen's kappas ranged from 0.86 for obsessive-compulsive PD to 0.93 for avoidant PD and schizoid PD, and were comparable with those in the previous interrater studies. The test-retest reliability of the SCID-II-PQ was moderately good, and after the SCID-II interview the test-retest reliability of the SCID-II appeared to be of almost perfect reliability. This first long-interval, large-sample, non-Western-language research on the test-retest reliability of the SCID-II for DSM-IV indicated its usefulness and excellent reliability.

[ERPs (N200, P300 and CNV) in alcoholics: relapse risk assessment]

The cognitive event-related potentials were studied in a group of 55 alcoholic patients, paired in age and sex with a group of 18 control subjects, using a protocol oddball (visual and auditory) and a protocol VCN Go/Nogo. The N200 obtained using an auditory oddball paradigm had lower amplitude in alcoholics than in controls. A significant amplitude decrease of visual P300 was also observed in alcoholic male subjects. There was however no difference in auditory P300 between alcoholics and control subjects. Using a Go/Nogo paradigm, a significant difference on the final part of the VCN appears between alcoholic and pilot subjects. In addition, the longitudinal follow-up of the same alcoholic patients showed an electrophysiological profile that allowed dividing them into two different groups. On the initial recording (17 days after weaning), the auditory oddball P300 amplitude was significantly higher at Cz and Pz among patients who relapsed during the 3 months follow-up. The same effect appeared on the CNV protocol, where the amplitude of P300 was higher in patients who subsequently relapsed than for those who remained abstinent. Cognitive ERPs may be clinically useful to improve the prediction of risk of relapse among alcoholic patients.

Reliability and validity of the borderline personality disorder severity index

The psychometric properties and validity of the Borderline Personality Disorder Severity Index (BPDSI), a semistructured interview assessing the frequency and severity of manifestations of Borderline Personality Disorder (BPD) during a circumscribed period, were investigated in two studies. In study 1, patients with BPD (n = 15), with other personality disorders (PD; n = 18), and without Axis II disorders (but with Axis I disorders; n = 10) assessed with the SCID were interviewed with the BPDSI (1-yr. version). Patients also filled out a number of questionnaires. A second rater judged taped BPDSI interviews. The BPDSI appeared to yield highly reliable (ICC = .93) and internally consistent (Cronbach's alpha = .85) scores. The BPDSI strongly discriminated BPD patients from other patients, and was not related to other Axis II pathology. Concurrent and construct validity was excellent. In study 2, a version of the BPDSI suitable for use in treatment outcome research was investigated (3-month version) in a sample of 64 BPD patients, 23 Cluster C PD patients, and 20 nonpsychiatric controls. Again, reliability coefficients were excellent (ICC = 0.97; Cronbach's alpha = 0.93), and validity indices were good. Clinical norms were also derived. In a sample of 28 BPD patients, the instrument detected improvement during 6 months of psychotherapy.

No evidence for overgeneral memories in borderline personality disorder

The hypothesis that borderline personality disorder (BPD) is related to overgeneral memories was tested in a mixed sample of 39 patients. A memory test with emotional cue words and the instruction to produce specific autobiographical memories was used. Specificity was judged by an independent rater. Regression analyses indicated that age and major depressive disorder were related to the production of less specific memories, whereas educational level and presence of personality disorder were positivily related to number of specific memories. Borderline personality disorder, anxiety disorders and childhood traumas were not related to number of specific memories.

Confiabilidade da "Entrevista Clínica Estruturada para o DSM-IV - Versão Clínica" traduzida para o português

OBJETIVOS: Verificar a confiabilidade da "Entrevista Clínica Estruturada para o DSM-IV - Versão Clínica (SCID-CV)" traduzida para o português. MÉTODOS: Foram submetidos, a duas entrevistas independentes (teste-reteste), 45 pacientes psiquiátricos em seguimento no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HC-FMRP/USP). Os dados foram analisados pelo Coeficiente Kappa (K). RESULTADOS: O Kappa ponderado foi excelente (Kw=0,83). A confiabilidade foi estatisticamente significante em transtorno do humor (K=0,87); transtornos psicóticos (K=0,90); transtornos relacionados ao uso de substância (K=0,76); transtornos de ansiedade (K=0,61); e nas categorias diagnósticas específicas analisadas, exceto em agorafobia sem história de transtorno do pânico (K=-0,04). CONCLUSÕES: A SCID-CV traduzida e adaptada para o português apresenta, em geral, boa confiabilidade, mas a ausência de questões e critérios diagnósticos específicos no próprio instrumento em diagnósticos, como agorafobia sem história de transtorno de pânico, diminuiu sua confiabilidade.

Evaluations of others by borderline patients

This study investigated evaluations of other people in specific emotional situations by patients with borderline personality disorder (BPD). BPD patients (N = 16), control patients with cluster C personality disorder (PD; N = 12) and normal controls (N = 15) saw film clips with emotional themes centering on abandonment, rejection and abuse, hypothesized to be specific for borderline pathology. Subjects wrote down their spontaneous reactions to six film personalities, divided over three clips, including what they thought to be characteristic traits of these persons. Spontaneous reactions were coded on two dimensions, based on earlier studies by Westen and colleagues: a) affect-tone of ascribed qualities and b) complexity of evaluations of people. The number of trait dimensions constituted the third scale. The overall pattern of findings suggests that the BPD group, as well as the cluster C group, show poorly differentiated evaluations with a low number of dimensions. Thus, this seems characteristic for personality disorders in general. The BPD group shows a lower affect-tone, reflecting a stronger tendency to view others negatively, compared with both control groups.

Response to cognitive therapy in depression: the role of maladaptive beliefs and personality disorders

This study examined whether personality disorder status and beliefs that characterize personality disorders affect response to cognitive therapy. In a naturalistic study, 162 depressed outpatients with and without a personality disorder were followed over the course of cognitive therapy. As would be hypothesized by cognitive theory (A. T. Beck & A. Freeman, 1990), it was not personality disorder status but rather maladaptive avoidant and paranoid beliefs that predicted variance in outcome. However, pre- to posttherapy comparisons suggested that although patients with or without comorbidity respond comparably to "real-world" cognitive therapy, they report more severe depressive symptomatology at intake and more residual symptoms at termination.

The SCL-90-R as a screening instrument for severe personality disturbance among outpatients with mood and anxiety disorders

Our objective was to examine whether the SCL-90-R, a widely used self-report measure of distress and psychopathology, could screen for personality disorders in general and for severe personality disturbance (SPD) in particular, at the time when patients seek treatment for a state (mood or anxiety) disorder. The SCL-90-R was administered to 112 consecutive outpatients with various mood and anxiety disorders. The personality severity index (PSI) score, defined as the mean value of the scores on the SCL-90-R subscales of interpersonal sensitivity, hostility, and paranoid ideation, was compared with the current symptom index (CSI) score, defined as the mean value of the scores on the remaining six SCL-90-R subscales. A positive screen was considered if PSI > CSI. SPD was defined as the presence of any DSM-III-R Cluster A and/or Cluster B personality disorder. The accuracy of the screen was verified by means of the Structured Clinical Interview for DSM-III-R Personality Disorders. The sensitivity of the PSI > CSI criterion to screen for SPD was 89.4%, while its sensitivity to screen for any DSM-III-R personality disorder was 72.9%. The SCL-90-R subscales that contributed the most to the screening discriminability of this SCL-90-R-derived screening measure were hostility, paranoid ideation, somatization, and obsessive-compulsive behavior. The SCL-90-R may be used to screen for SPD in routine work with outpatients with mood and anxiety disorders, but the results of the screening need to be verified because of the possibility of false negatives and false positives, although that possibility is apparently low. These findings may have important prognostic and treatment implications.

Prevalence of personality disorders among combat veterans with posttraumatic stress disorder

Many combat veterans with PTSD have co-occurring symptoms of other forms of psychopathology; however, there have been limited studies examining personality disorders among this population. The few extant studies typically have assessed only two or three personality disorders or examined a small sample, resulting in an incomplete picture and scope of comorbidity. This study assessed all DSM-III-R personality disorders in 107 veterans in a specialized, inpatient unit. Using the Structured Clinical Interview for DSM-III-R Personality Disorders, 79.4% of the participants were diagnosed with at least one personality disorder: 29.9% received only one diagnosis, 21.5% had two, 15.9% had three, and 12.1% had four or more. The most frequent single diagnoses were Avoidant (47.2%), Paranoid (46.2%), Obsessive-Compulsive (28.3%), and Antisocial (15.1%) personality disorders.

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.

Patient-informant concordance on the Structured Clinical Interview for DSM-III-R personality disorders (SCID-II)

In the assessment of personality disorders, patients reports can be questioned for several reasons, such as lack of insight, shame, and acute psychiatric state. High concordance between patient-based and informant-based diagnoses would be an indication of the validity of patient reports (convergent validity). The present study examined the concordance between 42 psychotherapy outpatients and their informants (intimates) on the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II). Similar to prior studies, low or only modest levels of agreement were found. In comparison with evaluations of the personality of the patient by the therapist, patient interviews seemed to be more valid than informant interviews. Furthermore, couples with high intensity and intimacy in the contact generally showed higher agreement than couples with low intensity and intimacy. In conclusion, the data slightly suggest that patient reports are more valid than informant reports. However, the lack of a golden standard forces us to find more evidence before concluding that patient reports on personality result in valid diagnoses.

Shared characteristics in the clinical expression and pharmacological responses of mental disorders and their possible collective significance

This paper points out the existence of, and enumerates, common characteristics spanning the clinical expression and pharmacological responses of most mental disorders. Central to the developed argument, the paper also points out an important overall property of brain function which normally insures a coordinated smoothness and synchronism across the expression of all the higher mental functions. Evidence from positron emission tomography studies supports the existence of a common initial structural abnormality which renders the brain vulnerable to a periodic loss of synchronism. This loss then expresses itself in a kind of 'psychic Parkinsonism', as shown in the characteristic, antithetical, oscillating format of the familiar cluster of symptoms of most mental disorders. The arguments are based on clinical observations and supported by a survey of the clinical and experimental literature.

Interrater reliability and internal consistency of the structured clinical interview for DSM-IV axis II personality disorders (SCID-II), version 2.0

Interrater reliability and internal consistency of the SCID-II 2.0 was assessed in a sample of 231 consecutively admitted in- and outpatients using a pairwise interview design, with randomized rater pairing and blind interview assessment. Interrater reliability coefficients ranged from .48 to .98 for categorical diagnosis (Cohen kappa), and from .90 to .98 for dimensional judgements (Intraclass correlation coefficient). Internal consistency coefficients were satisfactory (.71-.94). The results suggest that the SCID-II 2.0 has adequate interrater and internal consistency reliability.

Personality disorders do not influence the results of cognitive and behavior therapy for obsessive compulsive disorder

This study examined whether categorical or dimensional personality disorder variables affected treatment outcome in a sample of 52 patients with obsessive compulsive disorder who followed a standardized cognitive behavior therapy program. Treatment consisted of 12 weekly sessions and was completed by 43 patients. The Structured Clinical Interview for DSM-III-R personality disorders (SCID-II) was taken before the start of treatment by an independent rater. The treatment outcome measures included questionnaires and a Behavioral Assessment Test. Measurements were taken before and after treatment, and at 1 and 6 month follow-up tests. After the first follow-up test, further treatment was provided if clinically indicated. Neither categorical, nor dimensional personality disorder variables affected treatment outcome significantly. The inclusion of drop-outs in the analyses, did not change these results. Therefore, patients with obsessive compulsive disorder and concomitant personality disorder pathology should not be excluded from cognitive or behavior therapy for their obsessive compulsive complaints. Attributing therapy failure to concomitant Axis II pathology should be approached with caution.

Development and validation of a computerized screening test for personality disorders in DSM-III-R

The available self-report instruments designed to measure personality disorder (PD) are time-consuming to administer and/or score and can be impractical for routine clinical use. There is a need for a computerized method of personality assessment based on contemporary systems of classification. A computerized DSM-III-R-based questionnaire was developed and validated against the structured clinical interview for DSM-III-R Axis-II disorders on a sample of 60 subjects. The computerized test showed moderate validity as a diagnostic instrument (mean kappa coefficient = 0.47). With adjusted cut-off scores it was valid as a screening instrument (mean sensitivity = 0.87). Antisocial, borderline and avoidant PD scores were strongly correlated across measures and not subject to significant observer bias.

Psychopathy and Axis I and Axis II psychiatric disorders in a forensic psychiatric population in Sweden

The relationship between psychopathy and mental disorders was investigated in 61 male subjects during a forensic psychiatric examination. The Psychopathy Checklist Revised (PCL-R) and the Structured Clinical Interview for DSM-III-R (SCID) were used for the assessments. Although psychotic subjects were excluded, the overall psychiatric morbidity in the study population was high. Comorbidity was common, irrespective of the degree of psychopathy. Psychopathy was strongly positively correlated with substance abuse/dependence but negatively correlated with depression. Almost all of the subjects with high PCL-R scores had DSM-III-R antisocial and/or borderline personality disorders. However, some subjects with antisocial personality disorders had medium or low PCL-R scores. When the subjects were reassessed with diagnoses of DSM-IV and ICD-10 personality disorders, the difference between psychopathy and antisocial personality disorder was reduced.

Predictors of (non-) response in depressed outpatients treated with a three-phase sequential medication strategy

The predictive value of eight domains or sets of variables including sociodemographic aspects, premorbid history, symptomatology, personality, social and diagnostic data are evaluated in depressed outpatients with a Hamilton Rating Scale for Depression (HRSD) score of at least 14. Patients were treated using a three-phase sequential treatment strategy. Of the 119 patients, 88 completed the trial. The HRSD-score at the end of phases I, II or III was used as an outcome measure. Patients with an initially high HRSD-score and an obsessive-compulsive personality had a greater chance of recovery, while patients with somatization and a passive-aggressive personality had less of a chance of recovery. Variables involving psychiatric history, premorbid history or symptomatology of the depression, were not significantly related to outcome. The endogenous/non-endogenous distinction was not a predictor of response.

SCID II interviews and the SCID Screen questionnaire as diagnostic tools for personality disorders in DSM-III-R

A modified version of the SCID Screen questionnaire covering 103 criteria by means of 124 questions was compared with SCID II interviews in 69 psychiatric patients. The correlation between the number of criteria fulfilled in the SCID II interviews or the questionnaires was 0.84. In the SCID interviews, 54% of the patients had a personality disorder. When the SCID Screen questionnaire was used, 73% had a personality disorder. When the cut-off level for diagnosis was adjusted, the frequency found by means of the SCID screen questionnaire or the interviews was roughly the same, 58% and 54%, respectively. The overall kappa for agreement between the SCID II interviews and questionnaire with adjusted cut-off was 0.78.

Reliability of the Structured Clinical Interview for DSM-III-R: an evaluative review

Research evaluating the reliability of the Structured Clinical Interview for DSM-III-R (SCID) is reviewed. Reliability procedures and studies are examined. Several versions of the SCID are covered, including the SCID-I (axis I disorders), SCID-II (axis II disorders), SCID-Positive and Negative Syndrome Scale (SCID-PANSS; functional-dimensional assessment for psychotic disorders), and SCID-Upjohn Version (panic disorder). The SCID has been found to yield highly reliable diagnoses for most axis I and axis II disorders. Suggestions for future research on the SCID are offered, particularly with respect to (1) the lack of studies in which SCID diagnoses are compared with diagnoses from unstructured interviews or other structured-interview formats, and (2) the need for a more natural evaluation of this instrument. Also, the importance of establishing norms and obtaining reliability data for underserved clinical populations is discussed.

Treatment of borderline personality disorder: a challenge for cognitive-behavioural therapy

Patients with so-called Borderline Personality Disorder are generally considered as extremely difficult to treat. Until recently, conceptualizations of this severe disorder on which cognitive-behavioural therapy could be based were underdeveloped. The present paper presents a cognitive formulation based on previous cognitive and behavioural conceptualizations, and on empirical evidence pertaining to the relationship between childhood traumas and Borderline Personality Disorder. It is assumed that chronic traumatic abuse or neglect in childhood has led to the development of almost unshakeable fundamental assumptions about others (dangerous and malignant), about one's own capabilities (powerless and vulnerable) and upon one's value as a person (bad and unacceptable). These are assumed to underlie the complex symptomatic presentation of borderline patients. A treatment protocol is described, which takes 1.5-4 years, and consists of 5 stages: (1) construction of a working relationship; (2) symptom-management (gaining more control over symptoms); (3) correction of thinking errors; (4) emotional processing and cognitive re-evaluation of the childhood trauma and schema changes; and (5) termination. A case example is presented, and a call for research into the efficacy of this approach is made.