Personality disorders at the crossroads

Early Intervention for Borderline Personality Disorder: Psychodynamic Therapy in Adolescents

OBJECTIVES

Borderline personality disorder (BPD) should be understood as a disorder of development (Streeck-Fischer 2008, 2013) that has its first manifestation in late childhood and adolescence. There are only few treatment studies of adolescents meeting the diagnostic criteria of borderline personality disorder, although early interventions for these patients are urgently needed (see Chanen & McCutcheon 2013). We examined the effectiveness of an inpatient psychodynamic therapy (PDT).

METHODS

Twenty-eight adolescents fulfilling the DSM-IV diagnostic criteria of borderline personality disorder were treated with psychodynamic therapy. The mean duration of treatment was 29.87 weeks (SD = 15.88). Outcomes were remission rates, GAF, GSI, SDQ, IIP and BPI scores. Assessments were made at admission and after treatment. Pre-post comparisons and comparisons with normative data were conducted.

RESULTS

At the end of treatment 39.29% of the patients were remitted. We found significant improvements for the GAF, GSI, SDQ, IIP (all p0.001) and the BPI (p = 0.006).

CONCLUSIONS

These clinically relevant improvements demonstrate the effectiveness of psychodynamic therapy in adolescents with borderline personality disorder and stress the usefulness of an early intervention for these patients.

Reliability and Hierarchical Structure of DSM-5 Pathological Traits in a Danish Mixed Sample

In this study we assessed the DSM-5 trait model in a large Danish sample (n = 1,119) with respect to reliability of the applied Danish version of the Personality Inventory for DSM-5 (PID-5) self-report form by means of internal consistency and item discrimination. In addition, we tested whether the five-factor structure of the DSM-5 trait model can be replicated in a Danish independent sample using the PID-5 self-report form. Finally, we examined the hierarchical structure of DSM-5 traits. In terms of internal consistency and item discrimination, the applied PID-5 scales were generally found reliable and functional; our data resembled the five-factor structure of previous findings, and we identified a hierarchical structure from one to five factors that was conceptually reasonable and corresponded with existing findings. These results support the new DSM-5 trait model and suggest that it can be generalized to other languages and cultures.

The role of co-morbid personality pathology in predicting self-reported aggression in patients with schizophrenia

BACKGROUND

Personality pathology affects behavioral patterns in patients with schizophrenia notwithstanding psychotic symptomatology. An investigation of the role of co-morbid personality pathology in the occurrence of aggression in schizophrenia is explored using both categorical and dimensional approaches to personality pathology.

METHODS

In a cross-sectional study we evaluate, in 97 patients diagnosed with schizophrenia, the effect of personality pathology on the occurrence of aggression in schizophrenia using both a categorical approach, as described in DSM-IV-TR Axis II, and a dimensional approach, as operationalized in the Dimensional Assessment of Personality Pathology-Basic Questionnaire (DAPP-BQ). We also employ mediation analyses to explore the extent to which dimensions within the DAPP mediate the relationship between co-morbid personality disorders and aggression.

RESULTS

Personality pathology accounts for aggression in schizophrenia. Both the categorical and the dimensional approaches equally well account for the occurrence of aggression, with each model accounting for 60% of the variance. Interestingly, the mediation analysis reveals that the association between categorically defined personality pathology and aggression is substantially mediated by the higher-order-trait dissocial behavior of the DAPP-BQ, accounting for 50.6 % of the total effect size.

CONCLUSION

Personality pathology can be a significant predictor of aggression in patients with schizophrenia. While both the categorical and the dimensional trait models of personality disorders equally explain the aggression data, much of the relationship between the categorically defined personality disorders and the occurrence of aggression in schizophrenia can be explained by the presence of dissocial behavior as operationalized in the DAPP-BQ dimensional model.

The structure of personality disorders: comparing the DSM-IV-TR Axis II classification with the five-factor model framework using structural equation modeling

Earlier factor analytical studies on the empirical validity of the DSM-IV-TR (American Psychological Association, 2000) Axis II classification have offered little support for the current three-cluster structure. In his large-scale meta-analysis of previously published personality disorder correlation matrices, O'Connor (2005) found four factors, corresponding to the neuroticism, extraversion, agreeableness, and conscientiousness domains of the five-factor model of personality. In the present study, this dimensional four-factor model and the categorical DSM three-cluster structure were fitted to the Assessment of DSM-IV Personality Disorders questionnaire (ADP-IV; Schotte & De Doncker, 1994) scale scores using structural equation modelling. The results strongly favored the dimensional model, which also resembled other well-founded four-factor proposals (Livesley, Jang, & Vernon, 1998; Widiger & Simonsen, 2005). Moreover, a multigroup confirmatory factor analysis showed that this model was highly invariant and thus generalizable across two large clinical (n = 1,029) and general population (n = 659) samples.

Adolescent eating disorders: treatment and response in a naturalistic study

This naturalistic study investigated the treatment and outcome of adolescents with eating disorders (EDs) in the community. Clinicians from a practice-research network provided data on ED symptoms, global functioning, comorbidity, treatment, and outcome for 120 adolescents with EDs. ED "not otherwise specified" was the most common ED diagnosed. After an average of 8 months of treatment, about one third of patients had recovered, with patients with anorexia nervosa showing the most improvement. Clinicians utilized a range of psychotherapy interventions and two thirds of the patients had received adjunct psychoactive medication. Although CBT showed the strongest association with outcome in a subsample characterized by poor relational/personality functioning, dynamic therapy was associated with better global outcome in the overall sample.

Personality subtypes in adolescents with eating disorders: validation of a classification approach

BACKGROUND

Research has identified three personality subtypes in adults with eating disorders (EDs): a high-functioning, an undercontrolled, and an overcontrolled group. The current study investigated whether similar personality prototypes exist in adolescents with EDs, and whether these personality prototypes show relationships to external correlates indicative of diagnostic validity.

METHODS

Experienced clinicians from an adolescent practice-research network provided data on ED symptoms, DSM-IV comorbidity, personality pathology, and family and developmental history for 120 adolescent patients with EDs.

RESULTS

Consistent with the findings from the adult literature, three types of personality pathology emerged in adolescents: High-functioning/Perfectionistic, Emotionally Dysregulated, and Avoidant/Depressed. The High-functioning prototype showed negative associations with comorbidity and positive associations with treatment response. The Emotionally Dysregulated prototype was specifically associated with externalizing Axis I and Cluster B Axis II disorders, poor school functioning, and adverse events in childhood. The Avoidant/Depressed prototype showed specific associations with internalizing Axis I and Clusters A Axis II disorders, poor peer relationships, poor maternal relationships, and internalizing disorders in first-degree relatives.

CONCLUSIONS

These data support the presence of at least three diagnostically meaningful personality prototypes in adolescents with EDs, similar to those found previously in adults. Diagnosis of adolescents with EDs may be usefully supplemented by the assessment of personality style.

Borderline personality organization and dissociation

The relationship between Kernberg's psychodynamic model of personality organization (PO) and dissociation has not yet been explored. Seventy-two nonclinical subjects and 222 psychiatric patients completed the Dissociative Experiences Scale and the Inventory of Personality Organization. Its Reality Testing subscale emerged as the most important predictor for all facets of dissociation. Discussing our results in the framework of Fonagy and coworkers' model of mentalization, we suggest that dissociation may reflect the preoedipal "pretend" mode of psychic functioning while impaired reality testing and psychotic experiences might be indicative of the "psychic equivalent" mode.

Latent structure of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition personality disorder criteria

AIMS

This study investigated the internal construct validity of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) personality disorders and explored alternative models to characterize the personality disorder traits. The relationship between the obtained personality disorder dimensions and measures of functioning and disability was examined.

METHODS

The subjects in the study were 742 community-residing individuals who participated in the Hopkins Epidemiology of Personality Disorders Study. The presence of DSM-IV personality disorder traits was assessed by psychologists using the International Personality Disorder Examination (IPDE). Confirmatory factor analysis was performed on all the IPDE criteria for each of the 10 personality disorders using the Mplus program. Exploratory factor analysis of all personality disorder traits was completed using the same program. Factor scores were correlated with subjects' GAF ratings and number of missed days from work for physical and psychological reasons.

RESULTS

A single underlying factor was found for the IPDE item criteria of avoidant and dependent personality disorder, with less evidence for the other 8 personality disorders. Five factors were retained as the dimensional accounting for the personality disorder criteria. These factors were named compulsive, neurotic avoidant, aloof, impulsive callous, and egocentric. Of the five factors, 4 were associated with evidence of diminished functioning.

CONCLUSIONS

The IPDE pathological personality traits did not empirically cluster according to the current DSM-IV axis II diagnostic system but instead defined 5 relatively independent PD symptom dimensions that were related to functional impairments.

Perceptions of contradictory communication from parental figures by adults with borderline personality disorder: a preliminary study

This study investigated a hypothesized correlation between contradictory responses from parental figures perceived in present-day interactions by adult subjects and the diagnosis of borderline personality disorder (BPD). One hundred subjects were given a questionnaire designed to assess the frequency of perceived parental response patterns divided into appropriate, conflicting, polarized, and neglectful categories. The BPD and a group subthreshold for the disorder endorsed significantly more conflicting and fewer appropriate responses for the first parental figure rated than did both patient control subjects and normal control subjects without BPD; a trend toward similar results was found for the second parental figure also. The frequency of polarized and neglectful responses was not significantly different among the groups. There was indirect evidence that BPD subjects did not engage in the defense mechanism of "splitting" when filling out the questionnaire. These results suggest that contradictory family communication patterns might be considered in models of ongoing reinforcement for dysfunctional BPD behavior.

A latent structure analysis of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Narcissistic Personality Disorder criteria

The aim of this study was to examine the latent structure of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), Narcissistic Personality Disorder (NPD) criteria in a group of 641 outpatients. The consecutively admitted outpatients were administered the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, Version 2.0, and the Personality Questionnaire. Both confirmatory and exploratory factor analyses (CFA and EFA, respectively) were used to evaluate whether the NPD criteria measure a single latent trait. Latent class analysis was used to assess the diagnostic accuracy of the individual DSM-IV NPD criteria. Mean above minus below a cut (MAMBAC) and maximum covariance (MAXCOV) taxometric analyses were used to evaluate whether the latent distribution of the DSM-IV NPD features is actually discrete. Both CFA and EFA results showed that the 9 DSM-IV NPD criteria loaded on 2 correlated factors. The latent class analysis results suggested a 3-class solution for NPD criteria; relevant differences in diagnostic efficiency were observed among the NPD criteria. MAMBAC and MAXCOV analyses provided consistent evidence of taxonic (ie, discrete) latent structure for NPD. This study gave only partial support to the validity of the DSM-IV NPD construct. Taxometric analyses indicated that a typological model is appropriate for describing NPD, but CFA and EFA suggested the existence of 2 distinct-albeit correlated-clusters of narcissistic features. As a whole, the DSM-IV criteria discriminated NPD from other personality disorders, but diagnostic accuracy statistics did not replicate the rank order of diagnostic efficiency of NPD criteria proposed by the DSM-IV.

Assessing personality disorders in a national mental health survey

BACKGROUND

The lack of established brief Personality Disorder (PD) screening instruments may account for the absence of PD data from previous national mental health surveys. This paper documents the measurement of PD in a large Australian survey, with a particular focus on the characteristics of the screening instrument and the consequences of its mode of administration and scoring.

METHODS

PD was assessed in the 1997 Australian National Survey of Mental Health and Wellbeing (N=10,641 adults) using the 59-item version of the International Personality Disorder Examination Questionnaire (IPDEQ), which was administered in a computerised format by trained non-clinical interviewers.

RESULTS

Normative profiles are reported for three IPDEQ scoring schemes (simple categorical, IPDEQ(S); ICD-10 criterion based categorical, IPDEQ(C); and dimensional scoring, IPDEQ(D)), together with an examination of the IPDEQ's psychometric properties and associations with Axis I comorbidity, disability, and selected psychosocial characteristics. The overall rate of ICD-10 PD in Australia was estimated to be 6.5%, although the categorical assessment of dissocial PD clearly provided an underestimate. PD was associated with younger age, poorer functioning, and a sevenfold increase in the number of comorbid Axis I disorders during the preceding 12 months.

CONCLUSIONS

While the methods used to assess PD in the national survey were constrained by project demands, the overall performance of the IPDEQ was considered satisfactory, based on data from a range of sources. In particular, although IPDEQ item and subscale revisions are recommended, evidence is presented suggesting that aggregate IPDEQ dimensional scores should provide useful self-report indices of the overall likelihood of PD.

A Conceptual and Psychometric Framework for Distinguishing Categories and Dimensions

An important, sometimes controversial feature of all psychological phenomena is whether they are categorical or dimensional. A conceptual and psychometric framework is described for distinguishing whether the latent structure behind manifest categories (e.g., psychiatric diagnoses, attitude groups, or stages of development) is category-like or dimension-like. Being dimension-like requires (a) within-category heterogeneity and (b) between-category quantitative differences. Being category-like requires (a) within-category homogeneity and (b) between-category qualitative differences. The relation between this classification and abrupt versus smooth differences is discussed. Hybrid structures are possible. Being category-like is itself a matter of degree; the authors offer a formalized framework to determine this degree. Empirical applications to personality disorders, attitudes toward capital punishment, and stages of cognitive development illustrate the approach.

The dimensionality of dependent personality disorder

The criteria for dependent personality disorder (DPD) in DSM-IV appear to fall into two categories: dependent and attachment behaviors. The relevance of this division was evaluated in a sample of 182 patients admitted to a national Norwegian psychiatric hospital. Principal Components Analysis of all items belonging to the most frequent personality diagnoses revealed six components. The items for DPD formed two components, labeled attachment/abandonment and dependency/incompetence. Two criteria for borderline personality disorder also loaded on the attachment/abandonment component, while six criteria for avoidant personality disorder loaded on the dependency/incompetence component. Early Maladaptive Schemas of abandonment and failure correlated significantly higher with the attachment/abandonment component than with the dependency/incompetence component.