A validity study of axis II of DSM-III

The relationship of impairment to personality disorder severity among individuals with specific axis I disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions

The present study examined one dimensional approach to personality disorders (PDs) in a large (n = 43,093), nationally representative sample of the U.S. population. Respondents were classified in four personality severity categories (no PD, subthreshold PD, simple PD, complex PD). Linear regression analyses were conducted to examine mental disability by PD severity for major DSM-IV substance use, mood and anxiety disorders. Significant increases in disability were observed between no PD and simple PD and between simple PD and complex PD for each Axis I disorder except drug dependence, but few differences in disability were found between no PD and subthreshold PD. This study found support for the clinical utility of the dimensional classification of PD severity with regard to the distinction between simple and complex PD and for a combined no PD-subthreshold PD level of severity. Future planned analyses will address the clinical utility of the classification prospectively, with a full battery of all Axis II PDs.

Narcissism at the crossroads: phenotypic description of pathological narcissism across clinical theory, social/personality psychology, and psychiatric diagnosis

This review documents two themes of emphasis found in phenotypic descriptions of pathological narcissism across clinical theory, social/personality psychology, and psychiatric diagnosis. Clinical theories of narcissism spanning 35 years consistently describe variations in the expression of pathological narcissism that emphasize either grandiosity or vulnerable affects and self-states. Recent research in social/personality psychology examining the structure of narcissistic personality traits consistently finds two broad factors representing Grandiosity-Exhibitionism and Vulnerability-Sensitivity-Depletion respectively. However, the majority of psychiatric criteria for narcissistic personality disorder (NPD) in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) emphasize expressions of grandiosity. By placing most of the diagnostic emphasis on overt grandiosity, DSM NPD has been limited by poor discriminant validity, modest levels of temporal stability, and the lowest prevalence rate on Axis II. Despite converging support for two phenotypic themes associated with pathological narcissism, psychiatric diagnosis and social/personality psychology research often focus only on grandiosity in the assessment of narcissism. In contrast, clinical theory struggles with a proliferation of labels describing these broad phenotypic variations. We conclude that the construct of pathological narcissism is at a crossroads and provide recommendations for diagnostic assessment, clinical conceptualization, and future research that could lead to a more integrated understanding of narcissistic personality and narcissistic personality pathology.

Psychological distress and functional impairment in patients with personality disorders

The study is aimed at investigating the impact of a personality disorder (PD) diagnosis, in terms of functional impairment and subjective distress, in order to better understand the burden of this diagnosis and its implications. Among the 462 consecutive psychiatric patients diagnosed with the DSM structured interview for Axis I, II and V diagnoses, almost 60% had PD. Patients with PD displayed considerable vulnerability and suffering in many domains, including finances and interpersonal relationships. Despite the educational and occupational similarities of PD patients and non-PD patients, the PD patients had more problems maintaining permanent job positions. They also had more symptomatic suffering and concerns about health than non-PD patients. Generally, the results were in line with findings in the literature but more thoroughly captured the challenges that PD patients face in various areas of life. Awareness of the frequent comorbidity of PD with Axis I disorders seems crucial in developing future treatment plans with an emphasis on psychosocial rehabilitation, vocational training and social support.

Narcissistic personality disorder: relations with distress and functional impairment

This study examined the construct validity of narcissistic personality disorder (NPD) by examining the relations between NPD and measures of psychologic distress and functional impairment both concurrently and prospectively across 2 samples. In particular, the goal was to address whether NPD typically "meets" criterion C of the DSM-IV definition of Personality Disorder, which requires that the symptoms lead to clinically significant distress or impairment in functioning. Sample 1 (n = 152) was composed of individuals receiving psychiatric treatment, whereas sample 2 (n = 151) was composed of both psychiatric patients (46%) and individuals from the community. Narcissistic personality disorder was linked to ratings of depression, anxiety, and several measures of impairment both concurrently and at 6-month follow-up. However, the relations between NPD and psychologic distress were (a) small, especially in concurrent measurements, and (b) largely mediated by impaired functioning. Narcissistic personality disorder was most strongly related to causing pain and suffering to others, and this relationship was significant even when other Cluster B personality disorders were controlled. These findings suggest that NPD is a maladaptive personality style which primarily causes dysfunction and distress in interpersonal domains. The behavior of narcissistic individuals ultimately leads to problems and distress for the narcissistic individuals and for those with whom they interact.

The distinction between personality disorder and mental illness

BACKGROUND

Proposals by the UK Government for preventive detention of people with 'dangerous severe personality disorders' highlight the unresolved issue of whether personality disorders should be regarded as mental illnesses.

AIMS

To clarify the issue by examining the concepts of psychopathy and personality disorder, the attitudes of contemporary British psychiatrists to personality disorders, and the meaning of the terms 'mental illness' and 'mental disorder'.

METHOD

The literature on personality disorder is assessed in the context of four contrasting concepts of illness or disease.

RESULTS

Whichever of the four concepts or definitions is chosen, it is impossible to conclude with confidence that personality disorders are, or are not, mental illnesses; there are ambiguities in the definitions and basic information about personality disorders is lacking.

CONCLUSIONS

The historical reasons for regarding personality disorders as fundamentally different from mental illnesses are being undermined by both clinical and genetic evidence. Effective treatments for personality disorders would probably have a decisive influence on psychiatrists' attitudes.

Psychotherapy of personality disorders

This article reviews recent research examining the effectiveness of treating personality disorders with psychotherapy. Despite the prevalence and seriousness of these conditions, and the extensive clinical writings about them, research on the treatment of personality disorders has been limited. Much of the research is hampered by a multitude of difficult issues. Research from the past 3 years is reviewed, with an eye toward what new contributions the studies have made to the psychotherapy literature. Implications of their findings are considered and recommendations for future research are made.

A profile analysis of personality disorders: beyond multiple diagnoses

The authors applied cluster analysis and multidimensional scaling to the analyses of 59 patients with personality pathology. Cluster analysis yielded eight typologies of patients: detached, anankastic, phobic, dramatic, erratic, emotional, milder emotional, and masochistic negativistic. Multidimensional scaling identified the dimensions of classifying patients: anxious rumination versus behavioural acting out, overall severity of personality pathology, and assertiveness versus withdrawal. Considering the distinction between personality disorder (dysfunctional personality) and abnormal personality (extreme personality), the following changes in current classification system are proposed: use of a hierarchy and exclusion criteria in a categorical-type model or use of a personality profile in a dimensional-trait model, in either case, with a dimensional rating for severity of psychopathology to define personality 'disorder'.

A mathematical typology analysis of DSM-III-R personality disorder classification: grade of membership technique

This study employed grade of membership (GoM) analysis in a clinical setting to determine if the DSM-III-R personality disorder (PD) diagnostic criteria cluster into recognizable disorders resembling the official axis II nosology. The GoM model, based on fuzzy-set theoretic concepts, explicitly examines medical diagnostic systems by quantitatively identifying and characterizing subpatterns of illness within a broad class. A semistructured assessment of 110 outpatients was performed for 12 PDs and their 112 diagnostic criteria. GoM analysis was performed using internal variables of the 112 PD criteria rated as present or absent. Demographic variables, axis I and II diagnosis (structured clinical Interview for DSM [SCID]), and treatment response (Global Adjustment Scale [GAS]) information were used as external validators. Four pure types (PT) provided the most satisfactory solution to the data. PT-I is characterized by marked maladaptive personality pathology, which is manipulative, egocentric, impulsive, and alloplastic. PT-II consists primarily of exaggerated socially anxious and detached traits. PT-III is sociably dependent and autoplastic. PT-IV is essentially asymptomatic. GoM provides a more parsimonious handling of the PD criteria than provided by classifying according to DSM categories. The analysis fails to confirm the natural occurrence of any single specific axis II PD or cluster.

Psychometric characteristics of the cluster B personality disorders under DSM-III-R and DSM-IV

A stated goal for the latest revision of the DSM was improving the performance of the Axis II system. To evaluate the degree to which this goal was achieved, we performed a psychometric analysis of the Cluster B personality disorders (PD) as they are defined under the DSM-III-R and its successor the DSM-IV. Ninety-four patients with a primary PD diagnosis were rated for the presence of DSM-III-R and DSM-IV Cluster B PD criteria. From this symptom level data, the convergence, divergence, and internal consistency of the Cluster B criteria sets were determined. Also, kappa values were computed between the DSM-III-R and DSM-IV versions of these disorders as an index of coverage or agreement across the two systems. The results indicated that, in general, the DSM-IV Cluster B PDs represent an improvement over their DSM-III-R predecessors. However, some psychometric limitations, particularly regarding the convergence of the criteria sets, continue to be present.

Predicting patient benefit from a group-oriented, evening treatment program

Patients with coexisting mood and personality disorders are a challenge to service care providers who offer treatment. The response of 190 patients with one or both disorders to an intensive group-oriented evening treatment program was investigated. Benefit was assessed using factors derived from pre-post outcome measures and from general impressions of program usefulness. A predictive model consisting of patient levels of psychological mindedness and psychodynamic work was applied. Results indicated that psychological mindedness was significantly related to psychodynamic work in the program, and work was related to general impressions of program usefulness. These results cross-validated findings from a previous study of a day-treatment program. Restricted range may have prevented finding significant results for the pre-post outcome factors. Clinical implications of the findings are discussed.

Content validity of the DSM-IV borderline and narcissistic personality disorder criteria sets

This study sought to empirically evaluate the content validity of the newly revised DSM-IV narcissistic personality disorder (NPD) and borderline personality disorder (BPD) criteria sets. Using the essential features of each disorder as construct definitions, factor analysis was used to determine how adequately the criteria sets covered the constructs. In addition, this empirical investigation sought to: 1) help define the dimensions underlying these polythetic disorders; 2) identify core features of each diagnosis; and 3) highlight the characteristics that may be most useful in diagnosing these two disorders. Ninety-one outpatients meeting DSM-IV criteria for a personality disorder (PD) were identified through a retrospective analysis of chart information. Records of these 91 patients were independently rated on all of the BPD and NPD symptom criteria for the DSM-IV. Acceptable interrater reliability (kappa estimates) was obtained for both presence or absence of a PD and symptom criteria for BPD and NPD. The factor analysis, performed separately for each disorder, identified a three-factor solution for both the DSM-IV BPD and NPD criteria sets. The results of this study provide strong support for the content validity of the NPD criteria set and moderate support for the content validly of the BPD criteria set. Three domains were found to comprise the BPD criteria set, with the essential features of interpersonal and identity instability forming one domain, and impulsivity and affective instability each identified as separate domains. Factor analysis of the NPD criteria set found three factors basically corresponding to the essential features of grandiosity, lack of empathy, and need for admiration. Therefore, the NPD criteria set adequately covers the essential or defining features of the disorder.

Time-limited group psychotherapy for patients with personality disorders: outcomes and dropouts

This study reports on the time-limited (18-month long) group therapy of 49 outpatients, most of whom were diagnosed with DSM-III-R, Axis II personality disorders (American Psychiatric Association, 1987). Although many patients did not complete the full course of treatment, those who did experienced many areas of change. Completers reported substantial changes in self-esteem, symptomatology, and diagnosability on Axis II. This type of group treatment appears to be a promising mode of intervention for those with personality disorders.

A model of time-effective group psychotherapy for patients with personality disorders: the clinical model

This article describes a model of time-limited psychotherapy for patients with personality disorders that emphasizes the group as a social microcosm. The patient population described is relatively high functioning, although the majority of the group members meet DSM-III-R (American Psychiatric Association, 1987) criteria for an Axis II diagnosis. The clinical model's key theoretical concepts, for example, interpersonal focus; active therapist stance; emphasis on group interaction and processes; use of time limits; primary care/intermittent treatment philosophy; and emphasis on patients' strengths, goals, and resources are described. The relationships between the phases of group therapy and the key theoretical concepts are delineated.

A comparison of DSM-III-R and ICD-10 personality disorder criteria in an out-patient population

This study reports the results of a comparison of DSM-III-R and ICD-10 personality disorder criteria by application of both sets of criteria to the same group of patients. Despite the clinical relevance of these disorders and the need for reliable diagnostic criteria, such a comparison has not previously been reported. DSM-III-R and ICD-10 have converged in their classification of personality disorders, but some important differences between the two systems remain. Personality disorder diagnoses from both systems were obtained in 52 out-patients, using the Standardized Assessment of Personality (SAP), a brief, informant-based interview which yields diagnoses in both DSM-III-R and ICD-10. For individual personality disorder diagnoses, agreement between systems was limited. Thirty-four subjects received a personality disorder diagnosis that had an equivalent form in both systems, but only 10 subjects (29%) received the same primary diagnosis in each system. There was a difference in rate of diagnosis, with ICD-10 making significantly more personality disorder diagnoses. The lower diagnostic threshold of the ICD-10 contributed most of this effect. Further modifications in ICD-10 Diagnostic Criteria for Research (DCR) and DSM-IV to the personality disorder category have been considered. The omission in DSM-IV of three categories unique to that system and the raising of the threshold in ICD-10 DCR, do seem to have been helpful in promoting convergence.

The morbidity of DSM-III-R dependent personality disorder

Dependent personality has long been discussed by clinicians, and by empirical researchers more recently. Little empirical evidence so far has been presented as the type and degree of disability with which it is associated. This report provides some empirical data in that regard. To examine this question, those with and without DSM-III-R dependent personality were compared in male veterans drawn from an outpatient psychiatry clinic (dependent and nondependent groups). Standardized interview assessments were used to determine axes I and II disorders and family history. The dependent personality disorder group had significantly lower socioeconomic status and poorer functioning in the family/home sphere. They had significantly more social phobia, borderline traits, and histrionic traits. In relatives, there was significantly more generalized anxiety disorder, simple phobia, drug abuse, and dramatic personality disorder cluster. There are clearly documentable vulnerabilities and morbidities associated with dependent personality disorder.

An empirical method to refine personality disorder classification using stepwise logistic regression modeling to develop diagnostic criteria and thresholds

This study of DSM-III-R personality disorder (PD) classification provides an empirical approach to determine (1) the discriminative power of each criterion and (2) the optimal number of criteria needed to diagnose the presence of each PD. A semistructured assessment of 110 outpatients was performed for the 11 PDs and their 104 diagnostic criteria. Sensitivity, specificity, and predictive powers were calculated for each criterion item. Logistic regression was performed to determine (1) univariate weightings of the individual criteria as applied to a given diagnosis, and (2) multivariate measures of the criteria that significantly improved the chi-square value in a stepwise fashion. The significant items were then equally weighted to calculate the optimal number needed to diagnose category membership. Of 104 PD criteria, 41 discriminated at a significance level of .05 or less, and each PD could be optimally diagnosed with fewer criteria than currently required. We can empirically reduce the number of criteria combinations comprising individual categories, decrease heterogeneity, and narrow diagnostic boundaries. This increases the likelihood of identifying etiological factors, predictors of clinical course, specific treatments, familial aggregation, and neurobiological correlates for the PD taxa.

Personality diagnosis and childhood care associated with adult marital quality

This paper reports on a continuation of previous research into the connection between childhood experience of relationships and adult relationships such as marriage. A group of 41 married, mixed psychiatric patients showed the strongest correlations between adult marital quality as measured by the Marital Adjustment Test and mother care, same sex parent care or lowest caring parent care, as measured by the Parental Bonding Instrument. There was little correlation between childhood care and adult marital quality in both subgroups; one group was composed of 24 patients with Axis I diagnosis alone and the other group was composed of 17 patients with personality disorder. Married patients with personality disorder, almost all of whom had an Axis I diagnosis as well, did report lower levels of both childhood care and adult marital quality compared with patients with Axis I diagnoses and no personality disorder. The possible significance of these findings is discussed.

A systematic assessment of the comorbidity of DSM-III-R personality disorders in alcoholic outpatients

To our knowledge, this is the first study to examine the systematic comorbidity of DSM-III-R personality disorders (PDs) in a sample of alcoholic outpatients. The extent and direction of overlap can provide a measure of heterogeneity and descriptive validity. Fifty sober alcoholic outpatients enrolled in a treatment program were assessed by Structured Clinical Interview for DSM-III (SCID) instruments for the presence of axis I and axis II disorders; 80% had either a coexistent axis I or II disorder, with 66% having an axis I disorder, 64% an axis II disorder, and 50% both axis I and II disorders. There were 84 PD diagnoses among the 32 PD patients (2.6/patient), with multiple diagnoses in 20 (62%). The most prevalent PD diagnoses were paranoid (44%), antisocial (20%), avoidant (20%), passive-aggressive (18%), and borderline (16%). Overlap was extensive and not confined to any one of the three designated axis II clusters. Poorer outcome was associated with the presence of PD. Personality variables may offer a means of further characterizing the heterogeneity observed in axis I disorders. Further refinement of the current system of PD classification and investigation into alternate models is needed.

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

This study presents data on the interrater reliability of a Dutch version of the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II). Seventy outpatients were interviewed before the start of their treatment by one rater, while a second rater observed. Both raters were instructed to make independent ratings and the second rater was not allowed to participate in the discussion. On criterion level, interrater reliabilities appear to be very good, with a few exceptions (most reliabilities are higher than 0.75). However, all 5 observation criteria had poor interrater reliabilities. Agreement on personality disorder, on the whole, was excellent (overall kappa = 0.80). The possible reasons why relatively lower reliabilities are found with some criteria are discussed. Finally, problems encountered during the interviews are addressed and possible adjustments of the SCID-II are suggested.

Interrater reliability of the Structured Clinical Interview for DSM-III-R, Axis II: schizophrenia spectrum and affective spectrum disorders

Three interviewers (second raters) blindly rated 15 audiotapes each of the Structured Clinical Interview for DSM-III-R, Axis II (SCID-II) administered to the first degree relatives of probands with either DSM-III-R schizophrenia, schizoaffective disorder, or bipolar disorder, for a total of 45 second ratings. Interrater reliability was determined using the intraclass correlation coefficient and ranged from 0.60 to 0.84. The previous studies of the reliability of structured interviews for diagnosing personality disorders are summarized and compared to the present findings. We conclude that the SCID-II can be reliably used to diagnose schizophrenia-spectrum and affective spectrum disorders in the first degree family members of probands with schizophrenic or bipolar affective disorders.

Treatment outlines for borderline, narcissistic and histrionic personality disorders. The Quality Assurance Project

Treatment outlines for Axis I disorders were published during 1982-1985. Treatment outlines for the DSM-III personality disorders are being published. This guide to the treatment of borderline, histrionic and narcissistic disorders was developed from the literature, from the opinions of practising psychiatrists and from the experience of nominated experts. Even though the treatment of patients who suffer from these disorders is very difficult, the surveys of outcome in the literature suggest that a majority of patients improve significantly with long term psychotherapy. In the present outline the expert committee describe a hypothetical model for the genesis of these disorders and outline the steps to be followed if therapy is to be optimal. The experts stress that therapy is often prolonged and difficult but can be rewarding. They caution that therapists are likely to require considerable special training and it is recommended that they seek supervision throughout the process of therapy.

Personality disorders in New Zealand hospitals

A survey was carried out of all patients admitted to New Zealand psychiatric hospitals over a 7-year period with a primary diagnosis of personality disorder. Despite a decrease in the total number of admissions, the relative totals for each personality disorder remained consistent. The personality categories differed significantly in terms of age, sex, marital status and committal status. These variables conformed closely to traditional clinical descriptions of the personality disorders, indicating that the reliability and utility of classical categorical systems may be greater than has been assumed in the literature. The DSM-III-R prototypical categories, which may possibly be a more natural representation of personality disorder syndromes, may be less useful than the traditional categories in clinical and research applications.

Chronic pain patients and the nonorganic physical sign of nondermatomal sensory abnormalities (NDSA)

The nonorganic physical sign of nondermatomal sensory abnormalities (NDSA) is frequently found in chronic pain patients. The presence of NDSA qualifies the patient for a potential DSM-III diagnosis of conversion disorder. DSM-III (Axis I and II) diagnoses and personality styles were assigned to 283 mixed chronic pain patients. Discriminant analysis was used to identify diagnoses and personality styles significantly related to NDSA. The demographic variables of workers' compensation (WC) status, age, sex, and race were used as control variables. The discriminant function comprised all control variable, and psychiatric diagnoses accounted for only 22.1% of the variance. Age and WC status, i.e., the demographic variables, explained most of the variance (16.8%), with psychiatric diagnoses adding little (5.3%). The vast majority of the variance is unexplained, indicating the presence of "unexplained" factors for the presence of NDSA in chronic pain patients.

Treatment outlines for paranoid, schizotypal and schizoid personality disorders. The Quality Assurance Project

Treatment outlines for paranoid, schizotypal and schizoid personality disorders were developed by having nominated experts consider their own views in the light of the treatment literature and the responses of practising psychiatrists. In the detailed recommendations it is clear that while patients with all three disorders often present for treatment in a crisis and often see no issue other than the resolution of the crisis, patients with schizoid personality disorder can use long-term psychotherapy to develop and change to the extent of no longer being handicapped.

Personality disorders: treatment of the nonpsychotic chronic patient

Nonpsychotic chronic patients are troublesome not only because of their psychosocial dysfunction, cognitive and affective impairments, and behavioral problems but also because they fail to meet the expectations of health care providers. All of these conditions can cause problems of interactive fit between these patients and their clinicians.

DSM-III diagnoses of patients with myofascial pain syndrome (fibrositis)

Rheumatology centers report that chronic pain patients with myofascial pain (fibrositis) are prone to psychiatric pathology. However, the distribution of DSM-III diagnoses in this population is unknown. This distribution is reported for 238 chronic pain patients with fibrositis. Statistical comparisons of men and women were also made with regard to the prevalence of each diagnosis, and the results were compared to published DSM-III diagnoses prevalence data for mixed chronic pain patients and rheumatology fibrositis patients. In our sample, women with fibrositis were equally as likely as men with fibrositis to have current depression. Within the general chronic pain population, women are more likely to have current depression. The incidence of current major depression and current and past major depression was much lower in our fibrositis sample than that reported by rheumatology programs. These results indicate that there may be psychiatric differences between chronic pain patients with and without fibrositis. Fibrositis patients in rheumatology programs may also be psychiatrically different from chronic pain program patients with fibrositis.

An appraisal of the DSM-III system

DSM-III is a major document in the history of psychiatry. The DSM-III system is here seen as an instrument that promotes the scientific development of psychiatry and the clarity of communication among psychiatrists. However a major theme of this review is that reliability does not ensure validity. While making this point it is recognized that the major defects in the DSM-III system result from scientific inadequacies inherent in present day psychiatry. This review also may be taken as an amplification of the statement in DSM-III-R that it is not a textbook. In particular the data required to arrive at diagnoses in the DSM-III system do not provide sufficient information to arrive at a comprehensive biopsychosocial case formulation, a shortcoming that has relevance for teaching and clinical practice.

The specificity of DSM-III schizotypal personality traits

The rate of DSM-III schizotypal personality traits was evaluated in three groups of adolescent offspring (ages 15-21), defined by the psychiatric diagnosis of their parents. Parental diagnoses included schizophrenic disorder (40 adolescents), affective disorder (35 adolescents), and 'no psychiatric disorder' (normal controls) parents (82 adolescents). The presence of the eight component features of schizotypal personality disorder was assessed from video-taped semistructured psychiatric interviews, subsequently rated by trained psychiatrists, blind to the parental psychiatric status of the subjects. The effect of age, sex, and social class on the pattern of prevalence results was examined. The expected specificity of DSM-III schizotypal personality traits to schizophrenia was not supported by the prevalence pattern of the traits. Rates of 2 or more, 3 or more, and 4 or more schizotypal personality features were highest in the parental psychiatric groups. The rates of schizotypal personality traits in adolescent offspring of affective disorder parents were as high as those previously reported for relatives of schizophrenic disorder probands.

The expert witness in psychology and psychiatry

The involvement of psychologists and psychiatrists within the legal arena continues to grow rapidly but remains highly controversial. Extensive research on clinical judgement provides a scientific basis for clarifying the growing disputes about the values of such professional activities. Studies show that professionals often fail to reach reliable or valid conclusions and that the accuracy of their judgements does not necessarily surpass that of laypersons, thus raising substantial doubt that psychologists or psychiatrists meet legal standards for expertise. Factors that underlie the research findings and implications for courtroom testimony are discussed.

Compensation and non-compensation chronic pain patients compared for DSM-III operational diagnoses

Two hundred and eighty-three mixed chronic pain patients, consecutive admissions, were diagnostically evaluated as per DSM-III, Axis I, Axis II or personality type psychiatric operational criteria. Controlling for primary organic treatment diagnosis, age and race, statistical comparisons were made between male compensation patients (n = 93) and male non-compensation patients (n = 23) and between female compensation patients (n = 38) and female non-compensation patients (n = 28) for all DSM-III diagnoses. Male compensation patients were significantly overrepresented for these diagnostic groups: conversion disorder (somatosensory type); combined personality disorders; and passive-aggressive personality disorder. Male non-compensation patients were significantly overrepresented for these diagnostic groups: no diagnosis on Axis I; combined personality types; and compulsive personality type. Female compensation patients were significantly overrepresented for conversion disorder (somatosensory) only. Female non-compensation patients were significantly overrepresented for generalized anxiety disorder and combined anxiety syndromes. Compensation chronic pain patients may be at risk for some psychiatric disorders not previously identified: conversion disorder (somatosensory), and personality disorders.

Borderline personality. A review of recent research

Borderline personality has been, for many years, a discredited diagnostic concept. In 1979 a review of the literature concluded that its validity status was very uncertain. The authors have reviewed research conducted since then and discuss it in terms of the Robins & Guze (1970) criteria. In spite of existing unclear issues, the balance is tipping in favour of the validity of borderline personality, as diagnosed with new research criteria. This development is taking place in the context of a growing interest in the area of personality disorders.

Characteristics of sheltered homeless families

To describe the characteristics of homeless families, we interviewed 80 homeless mothers and 151 children living in 14 family shelters in Massachusetts (two-thirds of the shelters in the state). Ninety-four per cent of the families were headed by women, 91 per cent were on AFDC (aid to families with dependent children), with twice as many as the state average having been on AFDC for at least two years; most had long histories of residential instability. Although 60 per cent had completed high school, only a third had worked for longer than one month. One-third of the mothers reported having been abused during their childhood, and two-thirds had experienced a major family disruption. At the time of the interview, almost two-thirds either lacked or had minimal supportive relationships and one-fourth of these named their child as the major support. Eighteen mothers were involved with the Department of Social Services because of probable child abuse or neglect. Seventy-one per cent of the mothers had personality disorders. In contrast to many adult homeless individuals, however, deinstitutionalized persons or those suffering from psychoses were not overrepresented. About 50 percent of the homeless children were found to have developmental lags, anxiety, depression, and learning difficulties, and about half required further psychiatric evaluation. Two-thirds described housing and social welfare agencies as not helpful. Given the many serious problems of the mothers and the difficulties already manifested by their children, comprehensive psychosocial and economic interventions must be made to interrupt a cycle of extreme instability and family breakdown.

Male and female chronic pain patients categorized by DSM-III psychiatric diagnostic criteria

Two hundred and eighty-three chronic pain patients, consecutive admissions to the Comprehensive Pain Center of the University of Miami School of Medicine, received an extensive psychiatric evaluation based upon the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-III) criteria and flowsheets. All patients received the following type of diagnoses: DSM-III axis I; DSM-III axis II, and personality type. The distribution of assigned diagnoses for the entire patient sample was reviewed and a statistical comparison between male and female patients was performed with regards to the prevalence of each diagnosis. Anxiety syndromes and depression of various diagnostic types were the most frequently assigned axis I diagnoses with over half the patient sample receiving each of these diagnoses. Males were significantly overrepresented in the axis I diagnoses of intermittent explosive disorders, adjustment disorders with work inhibitions, and alcohol abuse and other drug dependence, while females were significantly overrepresented in disorders of current depression of various diagnostic types and somatization disorders. 58.4% of the patients fulfilled criteria for axis II personality disorder diagnoses. The most frequently personality disorders found in the patient group were dependent (17.4%), passive aggressive (14.9%), and histrionic (11.7%). Males were significantly overrepresented in paranoid and narcissistic disorders while females were overrepresented in histrionic disorder. The most frequent personality types found in the patient group were compulsive (24.5%) and dependent (10.6%). All personality types were similarly distributed between the sexes. The results of the present study were compared to a previous study of DSM-III diagnoses in chronic pain patients and are discussed in terms of the prevalence of DSM-III diagnoses in the general population. Questions are raised as to the applicability of certain DSM-III diagnoses in the chronic pain population.