Effects of sex and sex roles on the perceived maladaptiveness of DSM-IV personality disorder symptoms

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

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

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

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

Evidence-based assessment of personality disorders

The purpose of this article is to provide a foundation for the development of evidence-based guidelines for the assessment of personality disorders, focusing in particular on integrated assessment strategies. The general strategy recommended herein is to first administer a self-report inventory to alert oneself to the potential presence of particular maladaptive personality traits followed by a semistructured interview to verify their presence. This strategy is guided by the existing research that suggests particular strengths of self-report inventories and semistructured interviews relative to unstructured clinical interviews. However, the authors also consider research that suggests that further improvements to the existing instruments can be made. The authors emphasize, in particular, a consideration of age of onset, distortions in self-perception and presentation, gender bias, culture and ethnicity, and personality change.

Impairment and distress associated with symptoms of male-typed and female-typed DSM-IV Axis-I disorders

Recent research has established a pattern of impairment and distress associated with the symptoms of DSM-IV Axis-II disorders such that personality disorders occurring more commonly among males are associated with more social and occupational impairment, but less personal distress, than personality disorders occurring more commonly among females. The current study examined whether a similar pattern exists for DSM-IV Axis-I disorders. Lay judges (N = 206) rated the social impairment, occupational impairment, and personal distress associated with the symptoms of six male-typed and six female-typed Axis-I disorders. Impairment and distress were associated with male-typed and female-typed Axis-I disorders in the same manner as personality disorders. Reasons for the emphasis of social and occupational impairment among male-typed disorders and distress among female-typed disorders are discussed.

Gender differences in personality traits and disorders

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

Construct Validity of the Relationship Profile Test: Impact of Gender, Gender Role, and Gender Role Stereotype

Research supports the construct validity of the Relationship Profile Test (RPT; Bornstein & Languirand, 2003), a 30-item, self-report measure of destructive overdependence (DO), dysfunctional detachment (DD), and healthy dependency. In this investigation, we assessed the relationships of gender, gender role, and gender role stereotype ratings to RPT subscale scores. In Study 1, we replicated earlier patterns of gender differences in RPT scores, assessed cross-sample consistency in gender difference effect sizes, and provided preliminary nonclinical norms for the RPT subscales. Study 2 showed that--as expected--DO items are perceived as stereotypically feminine, whereas DD items are perceived as stereotypically masculine. In Study 3, we examined the relationships of RPT subscale scores to masculinity, femininity, and androgyny scores. We discuss the theoretical, empirical, and clinical implications of these findings.

MULTIVARIATE ANALYSIS OF PERCEIVED DYSFUNCTION RATINGS OF PERSONALITY DISORDER SYMPTOMS

Dysfunction in personality disorder symptoms was assessed using multivariate techniques to analyse lay judges' (N = 216) ratings of occupational impairment, social impairment, and personal distress. Factor analysis revealed that ratings of occupational impairment and social impairment loaded onto distinct factors. Personal distress ratings loaded onto two separate factors: high distress and low distress. Multidimensional scaling revealed two dimensions for overall dysfunction among personality disorders: severity of dysfunction and internalization-externalization. The dimensions were independence-dependence and severity of dysfunction for occupational impairment, interpersonal involvement and dominance-submission for social impairment, and internalization-externalization and severity for personal distress.

Effect of patient sex, clinician sex, and sex role on the diagnosis of Antisocial Personality Disorder: Models of underpathologizing and overpathologizing biases

This study examined the influence of patient sex and clinician sex and sex role for a case, meeting minimum diagnostic criteria for Antisocial Personality Disorder, in which patient sex was varied. The purpose was to provide an in-depth evaluation of the process by which patient sex and characteristics of clinicians may contribute to bias in personality disorder diagnoses. Psychologists (N = 167) read two cases, including the target case, and provided symptom ratings and diagnoses. A sex-unspecified condition served as a baseline to assess for over- and underpathologizing bias, and diagnoses based on the symptom ratings were compared to assigned diagnoses. Clinician sex role was assessed using the Bem Sex Role Inventory-Short Form. Results revealed that bias occurred when the patient's sex (female) was inconsistent with the gender weighting of the symptoms in the case (masculine), but the direction of the bias was consistent with sex roles (underdiagnosis of sex-role-inconsistent diagnoses, overdiagnosis of sex-role-consistent diagnoses). Path models of over- and underdiagnostic bias were developed using structural equation modeling. Patient sex had a direct effect on diagnostic ratings whereas clinician sex role had an indirect effect through symptom ratings.

Personality disorders at the crossroads

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

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

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

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

The antisocial, narcissistic, dependent, histrionic, and borderline personality disorders often obtain differential sex prevalence rates. One explanation has been that the diagnostic criteria for these personality disorders have different gender implications for maladaptivity (e.g., perhaps the dependent personality disorder diagnostic criteria are considered by clinicians to be more pathological for women than for men). This hypothesis was explored in two studies that obtained judgments by professional clinicians of the maladaptivity and statistical infrequency of personality disorder diagnostic criteria. Significant differences across gender were obtained for the frequency of diagnostic criteria but not for their maladaptivity. The personality disorder diagnostic criteria appear to be gender neutral with respect to their implications for maladaptivity.