Using the PAI with an eating disordered population: scale characteristics, factor structure, and differences among diagnostic groups

Assessment of suicidal thoughts and behaviors in adults: A systematic review of measure psychometric properties and implications for clinical and research utility

High-quality clinical care and research on suicidal thoughts and behaviors (STBs) depends on availability and implementation of reliable and valid measures of STBs. In contrast to studies examining STB risk factors, screening instruments, or treatment, little research has rigorously examined the content, characteristics, and psychometric properties of STB measures themselves. This systematic review (1) identified STB measures that conform to empirically supported definitions of STBs, and (2) identified peer-reviewed papers reporting on the psychometric properties of these measures in adults. Data on psychometric properties and other measure characteristics were extracted. A total of 21 eligible measures were identified in the first stage. In the second stage, 70 articles (with 79 independent samples) were included with psychometric data in adult samples for 19 measures. Although there was support for strong internal consistency and content validity across many measures, face validity and clinical utility concerns were prevalent. Few measures comprehensively assessed suicidal behaviors, and interview-based assessments tended to show the strongest psychometric properties and clinical utility. Findings are discussed in the context of recommendations for improving existing measures, including future research to increase utility and translatability across clinical settings, delivery methods, and diverse populations.

Emotional functioning in long COVID: Comparison to post-concussion syndrome using the Personality Assessment Inventory

Objective: Recent studies on Long COVID found that patients report prominent emotional distress and significant correlations between distress and cognitive performance have been identified, raising the question of how to manage or treat these issues. To understand psychological functioning in Long COVID further, this study examined personality responses on the Personality Assessment Inventory (PAI) to compare psychological functioning in a Long COVID group with a post-concussion syndrome (PCS) group, a syndrome with a significant psychological component. Participants and methods: Participants included 201 consecutive Long COVID outpatients (Mean age = 48.87 years, mean education = 14.82, 71.6% Female, 82.6% White) and a comparison group of 102 consecutively referred PCS outpatients (Mean age = 46.08, mean education = 14.17, 63.7% Female, 88.2% White). Effect sizes and t-tests were calculated using the PAI validity, clinical, interpersonal, and treatment consideration scales as well as clinical subscales. Results: The results replicated earlier findings on the PAI in Long COVID by demonstrating that both Long COVID and PCS groups had the highest mean elevations on SOM and DEP scales but no statistically significant between group differences in mean scale elevations. Results support similarities in psychological functioning between Long COVID and PCS patients emphasizing the importance of evaluating psychological functioning in neuropsychological evaluations for these populations. Further, results suggest that psychological treatment strategies for PCS patients may be helpful for Long COVID patients, but more research is needed.

Outcomes in post-acute sequelae of COVID-19 (PASC) at 6 months post-infection part 2: Psychological functioning

Limited research investigating the long-term psychological and emotional correlates of COVID-19 infection has been completed. The current study begins to address this limitation in patients experiencing Post-Acute Sequelae SARS-CoV-2 (PASC; e.g. "Long COVID").

Participants were 43 consecutive neuropsychological outpatients diagnosed with PASC and who completed the Personality Assessment Inventory (PAI). The sample was predominantly female (n = 36) and white (n = 32). Effect sizes compared to the normative mean T scores and base rates of elevated (T > 69) scores were calculated.

PAI scales measuring somatic preoccupation and depression had large effect sizes and the highest base rates of scale elevations, with the mean T score at approximately the normative cutoff for clinical significance (T = 70). The Schizophrenia Thought Disorder subscale (SCZ-T) also had a large effect size and high base rate of elevation, likely reflecting cognitive concerns. Scales measuring anxiety had medium effect sizes. The other PAI scales generally had small to negligible effect sizes. There were no significant differences between hospitalized and non-hospitalized participants on the PAI.

Overall, PAI scales measuring psychological distress, particularly somatic preoccupation and depression, were the most frequently elevated in the participants. The specific reasons for somatic preoccupation could not be determined in this study. Potential explanations include a vulnerability to distress in Long COVID patients, premorbid somatic preoccupation perhaps motivating these patients to seek clinical attention, or socioenvironmental factors leading some COVID patients to be somatically preoccupied with minor physiological changes and attribute those changes to COVID-19.

Preoperative Psychological Assessment and Weight Loss Outcomes in Bariatric Surgery Patients at a Military Treatment Facility: A Retrospective Profile Analysis

INTRODUCTION

Research on effectiveness of preoperative psychological measures as predictors of weight loss success and weight regain following bariatric surgery has been inconsistent. Despite mixed findings, preoperative psychological assessment instruments are used routinely, including in military medical facilities. Health concerns associated with obesity potentially impact military family readiness, with accompanying utilization of medical resources. Examining psychological factors associated with successful bariatric surgery outcomes may help to optimize care.

MATERIALS AND METHODS

This retrospective, observational study sought to identify characteristic elevations on two recommended preoperative psychological assessment instruments for bariatric surgery candidates: the Personality Assessment Inventory (PAI) and the Millon Behavioral Medicine Diagnostic (MBMD). Additionally, profile analysis was performed on assessment scales based on groupings of whether or not patients (N = 194) met their ideal BMI over a 60-month period. The Institutional Review Board at Madigan Army Medical Center approved this study protocol.

RESULTS

Means and standard deviations for PAI and the MBMD are presented for this sample of benefits-eligible patients in the military health system. Measures between bariatric outcome groups were not significantly different, but characteristic elevations for bariatric surgery candidates overall were identified.

CONCLUSION

The average elevations of scales were not above clinical cutoff, but still indicate characteristic trends in patients undergoing surgery at an MTF. These scales may be important to attend to with bariatric surgery candidates, especially scales which are related to psychopathology, treatment prognosis, and treatment management. Study results about scale elevations on preoperative psychological assessment instruments may help patients better manage bariatric surgery and can lead to enhanced warfighter readiness and decreased utilization of healthcare resources. Future work should examine postoperative behavioral and psychological factors, as the adjustment to lifestyle limitations of bariatric surgery is substantial.

An Integrative Approach to Clinical Decision-Making for Treating Patients With Binge-Eating Disorder

Transtheoretical integrative decision-making models help clinicians to use patient factors that are known to predict outcomes in order to inform individualized treatment. Patient factors with a strong evidence base include: functional impairment, social support and interpersonal functioning, complexity and comorbidity, coping style, level of resistance, and level of subjective distress. Among those with binge-eating disorder (BED), patient factors have not been extensively characterized relative to norms or other clinical samples. We used an integrative decision-making model of these six patient factor domains related to patient outcomes to characterize a sample of 424 adults seeking treatment for BED. Data were from medical charts, a demographics questionnaire, and validated psychometric scales. We then compared these data to published data from normative and other eating disorder (ED) samples. Results showed that the average patient with BED: (1) was significantly more functionally impaired compared to non-clinical norms but somewhat less impaired than other patients with ED, (2) demonstrated clinically significant problems in social support and interpersonal functioning, (3) presented with complex comorbid pathology and high levels of chronicity, (4) used a more internalizing coping style compared to the norm and other ED samples, (5) had low levels of resistance to interventions, and (6) experienced a moderately high level of subjective distress indicating good motivation for treatment. Corresponding recommendations to these findings are that the average patient with BED should be provided higher intensity treatment that is longer in duration, interpersonally focused, directive in nature, and emphasizing self-reflection and insight. Despite the nomothetic nature of the findings, clinicians are encouraged to assess these patient domains when developing an ideographic case conceptualization and to tailor precision treatment to the individual patient with BED.

Psychopathology Factors That Affect the Relationship Between Body Size and Body Dissatisfaction and the Relationship Between Body Dissatisfaction and Eating Pathology

Although high body mass index (BMI) alone does not invariably lead to body dissatisfaction (BD) and BD alone does not invariably lead to eating pathology (EP), research has suggested that there are clear relationships between each predictor and its respective criterion. We have a limited understanding of the factors that explain why some women at higher risk for BD (because of their BMI) do not report being dissatisfied with their bodies and why some women who are highly dissatisfied, do not engage in pathological eating behaviors. The present study examined such factors. A university sample of New Zealand women (N = 166) completed the Personality Assessment Inventory (Morey, 1991) and questionnaires measuring BD and EP. The tendency to report lower BD than would be predicted by one's BMI, and the tendency to report lower EP than would be expected based on one's BD, were characterized by lower overall distress (i.e., lower levels of anxiety and depression) and greater mood stability compared to those who followed the predicted outcome. Greater understanding of the factors that protect high-risk women from BD and EP may contribute to prevention and intervention strategies.

Validity and reliability of the attention deficit hyperactivity disorder self-report scale (ASRS-v1.1) in a clinical sample with eating disorders

Individuals with eating disorders (EDs) commonly experience comorbid attention deficit hyperactivity disorder (ADHD). The shared features of EDs and ADHD, such as inattention, impulsivity and hyperactivity, may exacerbate ED symptomatology and pose challenges to treatment. It is important to screen patients with EDs for symptoms of ADHD to optimize their treatment outcomes. However, the psychometrics of common measures of ADHD have not yet been examined within an ED population. An example of such a measure is the ADHD self-report scale (ASRS-v1.1) symptom checklist, which identifies the presence of ADHD symptoms. This study reports a psychometric study of the ASRS-v1.1 in a clinical sample of 500 adults with an ED. A confirmatory factor analysis indicated the ASRS-v1.1 maintained its two-factor structure of inattention and impulsivity/hyperactivity. The item loadings demonstrated path invariance across ED diagnostic groups indicating construct validity. Further, the subscales exhibited good internal consistency and they were significantly correlated with other measures of impulsivity indicating convergent validity. The ED sample had significantly higher mean scores than published nonclinical norms indicating predictive validity, but the ASRS-v1.1 scores were not significantly different among ED diagnostic groups. Results suggest the ASRS-v1.1 is a valid and reliable screening tool for identifying symptoms of ADHD among adults seeking treatment for ED.

Psychometric Properties of the Eating Disorders Inventory-2 among Women Seeking Treatment for Binge Eating Disorder

Psychometric properties of the Eating Disorders Inventory-2 (EDI-2) when used for women with Binge Eating Disorder (BED) are assessed. The EDI-2 was administered to 144 outpatients seeking treatment for BED and 152 outpatients seeking treatment for Bulimia Nervosa (BN). Most EDI-2 scales had acceptable internal consistence for both the BED and BN samples. EDI-2 scales demonstrated adequate stability within a subsample of those with BED who were retested. Confirmatory factor analyses revealed a hypothesized second-order two-factor structure for the original EDI scales for the BED group but not for those with BN. When the provisional EDI-2 scales were included, a two-factor structure was not supported for any group. Some scales differentiated the BED from the BN sample, and the second-order factors correlated with measures of similar constructs. The original EDI scales can be used reliably for those with BED.

Does the interpersonal model apply across eating disorder diagnostic groups? A structural equation modeling approach

BACKGROUND

Interpersonal model has been validated with binge-eating disorder (BED), but it is not yet known if the model applies across a range of eating disorders (ED).

PURPOSE

The goal of this study was to investigate the validity of the interpersonal model in anorexia nervosa (restricting type; ANR and binge-eating/purge type; ANBP), bulimia nervosa (BN), BED, and eating disorder not otherwise specified (EDNOS).

PROCEDURE

Data from a cross-sectional sample of 1459 treatment-seeking women diagnosed with ANR, ANBP, BN, BED and EDNOS were examined for indirect effects of interpersonal problems on ED psychopathology mediated through negative affect.

RESULTS

Findings from structural equation modeling demonstrated the mediating role of negative affect in four of the five diagnostic groups. There were significant, medium to large (.239, .558), indirect effects in the ANR, BN, BED and EDNOS groups but not in the ANBP group. The results of the first reverse model of interpersonal problems as a mediator between negative affect and ED psychopathology were nonsignificant, suggesting the specificity of these hypothesized paths. However, in the second reverse model ED psychopathology was related to interpersonal problems indirectly through negative affect.

CONCLUSION

This is the first study to find support for the interpersonal model of ED in a clinical sample of women with diverse ED diagnoses, though there may be a reciprocal relationship between ED psychopathology and relationship problems through negative affect. Negative affect partially explains the relationship between interpersonal problems and ED psychopathology in women diagnosed with ANR, BN, BED and EDNOS. Interpersonal psychotherapies for ED may be addressing the underlying interpersonal-affective difficulties, thereby reducing ED psychopathology.

Factor structure and construct validity of the Eating Disorder Examination-Questionnaire in college students: further support for a modified brief version

OBJECTIVE

The Eating Disorder Examination-Questionnaire (EDE-Q) is widely used in research studies across clinical and nonclinical groups. Relatively little is known about psychometric properties of this measure and the available literature has not supported the proposed scale structure. This study evaluated the factor structure and construct validity of the EDE-Q in a nonclinical study group of young adults.

METHOD

Participants were 801 young adults (573 females and 228 males) enrolled at a large public university in the Midwestern United States who completed the EDE-Q and a battery of behavioral and psychological measures.

RESULTS

Confirmatory factor analysis (CFA) revealed an inadequate fit for the original EDE-Q structure but revealed a good fit for an alternative structure suggested by recent research with predominately overweight/obese samples. CFA supported a modified seven-item, three-factor structure; the three factors were interpreted as dietary restraint, shape/weight overvaluation, and body dissatisfaction. Factor loadings and item intercepts were invariant across sex and overweight status. The three factors had less redundancy than the original EDE-Q scales and demonstrated improved convergent and discriminant validity in relation to relevant other measures.

DISCUSSION

These factor-analytic findings, which replicate findings from studies with diverse predominately overweight/obese samples, supported a modified seven-item, three-factor structure for the EDE-Q with improved psychometric characteristics. The findings provide further empirical support for the distinction between body dissatisfaction and overvaluation and have implications for assessment and research. These findings need to be replicated in samples of persons with eating-disorder psychopathology including those with anorexia nervosa, bulimia nervosa, and allied states.

Validity and reliability of the behavior rating inventory of executive function - adult version in a clinical sample with eating disorders

This study is a preliminary investigation of the reliability and validity of the Behavior Rating Inventory of Executive Function - Adult Version (BRIEF-A) in a clinical sample of patients with eating disorders (ED). Participants were 252 adult females who were referred to a centre for the treatment of EDs, as well as 31 individuals who completed the informant version of the BRIEF-A. Patients completed the BRIEF-A and other psychological measures on one occasion during their initial clinic visit, and informants nominated by patients completed the informant version at home. Reliability analyses revealed high internal consistency (Cronbach's alpha) of the two indices (Metacognition Index and Behavioral Regulation Index), and for the Global Executive Composite (GEC) of the BRIEF-A (α = .96). Convergent validity was shown by a high positive relationship between the self-report and informant-report versions of the BRIEF-A, and between the GEC and the Anxiety and Depression scales. Construct validity was assessed by an exploratory and confirmatory factor analysis. The BRIEF-A may be a reliable and valid tool for measuring executive functioning (EF) in an ED population, and may serve as an initial screening tool of EF for clinicians and researchers.

Personality Assessment Inventory profiles of university students with eating disorders

BACKGROUND

Eating disorders are complex disorders that involve medical and psychological symptoms. Understanding the psychological factors associated with different eating disorders is important for assessment, diagnosis, and treatment.

METHODS

This study sought to determine on which of the 22 Personality Assessment Inventory (PAI) scales patients with anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified (EDNOS) differed, and whether the PAI can be used to classify eating disorder subtypes. Because we were interested in both whether the PAI could be used to differentiate eating disorder subtypes from each other, as well as from other disorders, we also included a group of patients with major depression.

RESULTS

The three eating disorder groups did differ significantly from each other, and from the patients with depression, on a number of the PAI scales. Only two PAI scales (Anxiety and Depression), however, exceeded a T-score of 70 for the patients with anorexia nervosa, no scales exceeded a T-score of 70 for the patients with bulimia nervosa or EDNOS, and only two exceeded a T-score of 70 for the patients with depression (Depression and Suicide). A discriminant function analysis revealed an overall correct classification between the groups of 81.6%.

CONCLUSIONS

The PAI helps to understand the psychological factors associated with eating disorders and can be used to assist with assessment. Continued investigation using the PAI in an eating disordered population is supported.

Purging disorder: psychopathology and treatment outcomes

OBJECTIVE

To characterize a tertiary care treatment-seeking sample and assess post-treatment remission and completion rates for purging disorder (PD).

METHOD

Consecutively admitted women with PD (n = 122), anorexia nervosa (AN) restricting subtype (AN-R; n = 146), AN binge-purge subtype (AN-B; n = 154), and bulimia nervosa-purging subtype (BN-P; n = 415) were compared on general and eating disorder specific psychopathology. A subsample (n = 256) attended a day treatment program and were assessed for post-treatment remission and completion rates.

RESULTS

PD occurred in 17.3% of eating disorders not otherwise specified and 6.7% of total eating disorder referrals. PD patients were similar to AN-B and BN-P, but had higher levels than AN-R, on general and eating disorder psychopathology. PD individuals did not have different post-treatment remission or completion rates compared to other eating disorders.

DISCUSSION

The results add to a growing literature on the utility of PD as a diagnosis.

Testing a maintenance model for eating disorders in a sample seeking treatment at a tertiary care center: a structural equation modeling approach

Fairburn et al (Fairburn, CG, Cooper, Z, Shafran, R. Behav Res Ther 2003;41:509-528) proposed additional maintenance mechanisms (ie, interpersonal difficulties, mood intolerance, low self-esteem, and perfectionism) for some individuals with eating disorders in addition to core eating disorder psychopathology (ie, overevaluation of eating, weight, and shape and their control). This is the first study to both elaborate and test this maintenance model as a structural model. Adults seeking treatment of an eating disorder (N = 1451) at a specialized tertiary care center were included in this cross-sectional study. In the first part of the study, diagnostically heterogeneous participants (n = 406) were randomly selected to test a structural model based on the maintenance model. In the second part of the study, remaining participants (n = 1045) were grouped according to eating disorder diagnosis to test for invariance of the structural paths of the final model across diagnoses. Overall, the structural model with core and additional mechanisms fit the data well and, with 1 exception, represented maintenance processes for each of the diagnostic groups. Treatment models based on both core and additional maintenance factors for those seeking therapy at a specialized tertiary care center may result in improved treatment outcomes for these patients with eating disorders.

Predictors of treatment acceptance and of participation in a randomized controlled trial among women with anorexia nervosa

OBJECTIVE

This study aimed to identify predictors of acceptance of intensive treatment and of participation in a randomized controlled trial (RCT) among women with anorexia nervosa (AN).

METHOD

Participant data were drawn from a tertiary care intensive treatment programme including a previously published RCT. Women with AN (N = 106) were offered intensive treatment, and 69 were approached to participate in an RCT of olanzapine's efficacy as an adjunctive treatment for AN. AN subtype and pretreatment psychological variables were used to predict acceptance of intensive treatment and RCT participation.

RESULTS

AN binge purge subtype and higher depression and body dissatisfaction predicted intensive treatment acceptance. No variable predicted RCT participation among treatment acceptors.

DISCUSSION

Clinicians may focus on enhancing motivation or use a stepped care approach to increase intensive treatment acceptance especially among women with AN-restricting type and among all those with AN who have lower levels of distress.

Personality dimensions among women with an eating disorder: towards reconceptualizing DSM

OBJECTIVE

To evaluate the incremental validity of a dimensional assessment of personality, after controlling for diagnostic category, in accounting for meaningful variation in eating disorder attitudes and behaviours and in current affective distress among a clinical sample of eating disordered women.

METHODS

244 treatment seeking eating disordered women and 116 non-eating disordered women were assessed with the NEO five factor inventory (NEO-FFI), and with measures of eating disorder attitudes and of affective distress using a cross sectional design.

RESULTS

As predicted, differences were found between eating disordered and non-eating disordered women on several NEO-FFI scales, which provided a context for subsequent analyses. NEO-FFI scales accounted for meaningful variation in eating disordered attitudes and behaviours as well as in levels of current affective distress over and above DSM-IV diagnostic category.

CONCLUSION

A flexible approach to diagnosis, which includes personality dimensions along with a description of eating disorder symptoms, may result in a more inclusive and useful diagnostic scheme for treating women with eating disorders.

An Item-Level Psychometric Analysis of the Personality Assessment Inventory

Multi-item multiscale self-report measures are increasingly used in inpatient assessments. When considering a measure for this setting, it is important to evaluate the psychometric properties of the clinical scales and items to ensure that they are functioning as intended in a highly distressed clinical population. The present study examines scale properties for a self-report measure frequently employed in inpatient assessments, the Personality Assessment Inventory (PAI). In addition to examining internal consistency statistics, this study extends prior PAI research by considering key issues related to inpatient assessment (e.g., scale distinctiveness, ceiling effects). Coefficient alphas, interitem correlations, and item— scale relationships suggest that the PAI clinical scales and subscales are internally consistent. Items for respective clinical scales generally showed significantly higher item—scale correlations with their intended scale (as compared with their item—scale correlation with scales they were not intended to measure). In addition, scales’ coefficient alpha scores were higher than their interscale correlations. Taken as a whole, these results support the hypothesis that PAI scales were measuring relatively distinct constructs in this inpatient sample. Findings are discussed with regard to the implications for scale interpretation in inpatient assessment, functioning of individual scales and subscales, and functioning of specific items. Limitations of the present study and directions for future research are discussed.

Pathoplasticity of bulimic features and interpersonal problems

OBJECTIVE

Recent research suggests that interpersonal problems and some forms of psychopathology are pathoplastic, or that they mutually affect one another in nonetiological ways. In the current study, the pathoplasticity of bulimic features and interpersonal problems was tested.

METHOD

Inventory of Interpersonal Problems-64 data from 130 women with scores in the top quartile on the Bulimia scale of the Eating Disorder Inventory-2 from a sample of 517 college undergraduates were cluster analyzed. Age, weight, and scores on psychopathology scales were tested for mean differences across the four quadrants of the interpersonal problems circumplex.

RESULTS

Consistent with the pathoplasticity hypothesis, cluster means did not differ on external variables. Furthermore, bulimic features and interpersonal problems independently predicted depression in the total sample.

CONCLUSION

The interpersonal problems reported in the current study suggest differential treatment process that could inform the therapeutic relationship and help prevent premature termination.

The Personality Assessment Inventory with chronic pain patients: Psychometric properties and clinical utility

The present study examined the clinical utility and psychometric properties of the Personality Assessment Inventory (PAI; Morey, 1991) within a large sample of chronic pain patients. Alpha coefficients and mean interitem correlations generally conformed with recommended psychometric standards and were similar to those reported for the test standardization samples. Factor analyses supported the consistency of the underlying factor structure of the PAI with chronic pain patients. The factor related to acting-out behavior did not contain the substance abuse component found in previous investigations. The findings demonstrate the complexity and heterogeneity of chronic pain cases and support the usefulness of the PAI in detecting broad and specific psychological and personality constructs within the population of chronic pain patients. Finally, the study provides normative data that will inform clinical interpretation and decision making in chronic pain cases. Overall, the results support the applicability of the PAI for assessment and treatment planning with chronic pain patients.

Attachment Predicts Treatment Completion in an Eating Disorders Partial Hospital Program Among Women With Anorexia Nervosa

The goal of this study was to examine if attachment theory can provide a framework for understanding treatment completion in an eating disorders partial hospital program among women with anorexia nervosa (AN). Attachment was measured using the Attachment Styles Questionnaire (Feeney, Noller, & Hanrahan, 1994). As hypothesized, self-reports of high avoidant attachment predicted noncompletion of treatment for those with AN binge-purge subtype (ANB). However, this relationship did not emerge for those with AN restricting subtype (ANR). Also as hypothesized, self-reports of high anxious attachment predicted completing treatment for those with ANB but not for those with ANR. For completers with ANB and ANR, the program was helpful in increasing body weight and lowering drive for thinness, body dissatisfaction, interpersonal problems, and depression. Attachment avoidance, characterized by devaluing one's need for relationships, may be a contraindication for group-based partial hospital treatment of ANB. Attachment anxiety, characterized by high preoccupation with relationships, may facilitate remaining in treatment for those with ANB.