Relating DSM-5 section III personality traits to section II personality disorder diagnoses

BACKGROUND

The DSM-5 Personality and Personality Disorders Work Group formulated a hybrid dimensional/categorical model that represented personality disorders as combinations of core impairments in personality functioning with specific configurations of problematic personality traits. Specific clusters of traits were selected to serve as indicators for six DSM categorical diagnoses to be retained in this system - antisocial, avoidant, borderline, narcissistic, obsessive-compulsive and schizotypal personality disorders. The goal of the current study was to describe the empirical relationships between the DSM-5 section III pathological traits and DSM-IV/DSM-5 section II personality disorder diagnoses.

METHOD

Data were obtained from a sample of 337 clinicians, each of whom rated one of his or her patients on all aspects of the DSM-IV and DSM-5 proposed alternative model. Regression models were constructed to examine trait-disorder relationships, and the incremental validity of core personality dysfunctions (i.e. criterion A features for each disorder) was examined in combination with the specified trait clusters.

RESULTS

Findings suggested that the trait assignments specified by the Work Group tended to be substantially associated with corresponding DSM-IV concepts, and the criterion A features provided additional diagnostic information in all but one instance.

CONCLUSIONS

Although the DSM-5 section III alternative model provided a substantially different taxonomic structure for personality disorders, the associations between this new approach and the traditional personality disorder concepts in DSM-5 section II make it possible to render traditional personality disorder concepts using alternative model traits in combination with core impairments in personality functioning.

Relating DSM-5 section III personality traits to section II personality disorder diagnoses

BACKGROUND

The DSM-5 Personality and Personality Disorders Work Group formulated a hybrid dimensional/categorical model that represented personality disorders as combinations of core impairments in personality functioning with specific configurations of problematic personality traits. Specific clusters of traits were selected to serve as indicators for six DSM categorical diagnoses to be retained in this system - antisocial, avoidant, borderline, narcissistic, obsessive-compulsive and schizotypal personality disorders. The goal of the current study was to describe the empirical relationships between the DSM-5 section III pathological traits and DSM-IV/DSM-5 section II personality disorder diagnoses.

METHOD

Data were obtained from a sample of 337 clinicians, each of whom rated one of his or her patients on all aspects of the DSM-IV and DSM-5 proposed alternative model. Regression models were constructed to examine trait-disorder relationships, and the incremental validity of core personality dysfunctions (i.e. criterion A features for each disorder) was examined in combination with the specified trait clusters.

RESULTS

Findings suggested that the trait assignments specified by the Work Group tended to be substantially associated with corresponding DSM-IV concepts, and the criterion A features provided additional diagnostic information in all but one instance.

CONCLUSIONS

Although the DSM-5 section III alternative model provided a substantially different taxonomic structure for personality disorders, the associations between this new approach and the traditional personality disorder concepts in DSM-5 section II make it possible to render traditional personality disorder concepts using alternative model traits in combination with core impairments in personality functioning.

Comparison of alternative models for personality disorders, II: 6-, 8- and 10-year follow-up

BACKGROUND

Several conceptual models have been considered for the assessment of personality pathology in DSM-5. This study sought to extend our previous findings to compare the long-term predictive validity of three such models: the five-factor model (FFM), the schedule for nonadaptive and adaptive personality (SNAP), and DSM-IV personality disorders (PDs).

METHOD

An inception cohort from the Collaborative Longitudinal Personality Disorder Study (CLPS) was followed for 10 years. Baseline data were used to predict long-term outcomes, including functioning, Axis I psychopathology, and medication use.

RESULTS

Each model was significantly valid, predicting a host of important clinical outcomes. Lower-order elements of the FFM system were not more valid than higher-order factors, and DSM-IV diagnostic categories were less valid than dimensional symptom counts. Approaches that integrate normative traits and personality pathology proved to be most predictive, as the SNAP, a system that integrates normal and pathological traits, generally showed the largest validity coefficients overall, and the DSM-IV PD syndromes and FFM traits tended to provide substantial incremental information relative to one another.

CONCLUSIONS

DSM-5 PD assessment should involve an integration of personality traits with characteristic features of PDs.

The association of personality disorders with the prospective 7-year course of anxiety disorders

BACKGROUND

This study prospectively examined the natural clinical course of six anxiety disorders over 7 years of follow-up in individuals with personality disorders (PDs) and/or major depressive disorder. Rates of remission, relapse, new episode onset and chronicity of anxiety disorders were examined for specific associations with PDs.

METHOD

Participants were 499 patients with anxiety disorders in the Collaborative Longitudinal Personality Disorders Study, who were assessed with structured interviews for psychiatric disorders at yearly intervals throughout 7 years of follow-up. These data were used to determine probabilities of changes in disorder status for social phobia (SP), generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), panic disorder and panic disorder with agoraphobia.

RESULTS

Estimated remission rates for anxiety disorders in this study group ranged from 73% to 94%. For those patients who remitted from an anxiety disorder, relapse rates ranged from 34% to 67%. Rates for new episode onsets of anxiety disorders ranged from 3% to 17%. Specific PDs demonstrated associations with remission, relapse, new episode onsets and chronicity of anxiety disorders. Associations were identified between schizotypal PD with course of SP, PTSD and GAD; avoidant PD with course of SP and OCD; obsessive-compulsive PD with course of GAD, OCD, and agoraphobia; and borderline PD with course of OCD, GAD and panic with agoraphobia.

CONCLUSIONS

Findings suggest that specific PD diagnoses have negative prognostic significance for the course of anxiety disorders underscoring the importance of assessing and considering PD diagnoses in patients with anxiety disorders.

Personality traits as prospective predictors of suicide attempts

OBJECTIVE

To examine higher order personality factors of negative affectivity (NA) and disinhibition (DIS), as well as lower order facets of impulsivity, as prospective predictors of suicide attempts in a predominantly personality disordered sample.

METHOD

Data were analyzed from 701 participants of the Collaborative Longitudinal Personality Disorders Study with available follow-up data for up to 7 years. Cox proportional hazards regression analyses was used to examine NA and DIS, and facets of impulsivity (e.g. urgency, lack of perseverance, lack of premeditation and sensation seeking), as prospective predictors of suicide attempts.

RESULTS

NA, DIS and all facets of impulsivity except for sensation seeking were significant in univariate analyses. In multivariate models which included sex, childhood sexual abuse, course of major depressive disorder and substance use disorders, only NA and lack of premeditation remained significant in predicting suicide attempts. DIS and the remaining impulsivity facets were not significant.

CONCLUSION

NA emerged as a stronger and more robust predictor of suicide attempts than DIS and impulsivity, and warrants greater attention in suicide risk assessment. Distinguishing between facets of impulsivity is important for clinical risk assessment.

Improvement in borderline personality disorder in relationship to age

OBJECTIVE

It is commonly believed that some features of borderline personality disorder (BPD) improve as individuals reach their late 30s and 40s. This study examined age-related change in borderline criteria and functional impairment, testing the hypothesis that older age would be associated with relatively more improvement than younger age.

METHOD

A total of 216 male and female participants with BPD were followed prospectively with yearly assessments over 6 years.

RESULTS

Participants showed similar rates of improvement in borderline features regardless of age. A significant age by study year interaction showed functioning in older subjects to reverse direction and begin to decline in the latter part of the follow-up, in contrast to younger subjects who maintained or continued improvement over the 6 years. Despite the decline, functioning for the older subjects was comparable with or slightly better at year 6 than at year 1.

CONCLUSION

Improvement in borderline features is not specific to the late 30s and 40s. There may be a reversal of improvement in functioning in some borderline patients in this older-age range.

Hierarchical relationships between borderline, schizotypal, avoidant and obsessive-compulsive personality disorders

OBJECTIVE

Comorbidity among personality disorders is widely considered problematic. The validity of one proposed solution, diagnostic hierarchies, was investigated in the current study with respect to borderline, schizotypal, avoidant, and obsessive-compulsive personality disorders.

METHOD

One approach used discriminant functions, derived from multiple psycho-social domains, that were used to classify comorbid individuals from the Collaborative Longitudinal Personality Disorder study (CLPS) to explore the possibility of hierarchical precedence of one personality disorder over another. A second approach examined the incremental increase in R(2)-value in predicting functioning and personality provided by each diagnosis over each other diagnosis.

RESULTS

Obsessive-compulsive personality disorder was consistently subordinate to other diagnoses, whereas other indications of hierarchical relationships were domain-specific.

CONCLUSION

Results indicate minimal support for an over-arching hierarchical pattern among studied personality disorders, and suggest the inclusion of all relevant diagnoses in clinical practice.

Longitudinal diagnostic efficiency of DSM-IV criteria for obsessive-compulsive personality disorder: a 2-year prospective study

OBJECTIVE

To examine the longitudinal diagnostic efficiency of the DSM-IV criteria for obsessive-compulsive personality disorder (OCPD).

METHOD

At baseline, criteria and diagnoses were determined using diagnostic interviews, and blinded assessments were performed 24 months later with 550 participants. Diagnostic efficiency indices (conditional probabilities, total predictive power, and kappa) were calculated for each criterion determined at baseline, using the independent OCPD diagnosis at follow-up as the standard.

RESULTS

Longitudinal diagnostic efficiencies for the OCPD criteria varied; findings suggested the overall predictive utility of 'preoccupied with details', 'rigid and stubborn', and 'reluctant to delegate'.

CONCLUSION

These findings suggest the predictive validity of three cognitive-interpersonal OCPD criteria.

Internal consistency, intercriterion overlap and diagnostic efficiency of criteria sets for DSM-IV schizotypal, borderline, avoidant and obsessive-compulsive personality disorders

OBJECTIVE

To evaluate performance characteristics of DSM-IV Personality Disorders (PDs) criteria.

METHOD

Six hundred and sixty-eight adults recruited for the Collaborative Longitudinal Personality Disorders Study (CLPS) were assessed with diagnostic interviews.

RESULTS

Within-category inter-relatedness was evaluated by Cronbach's alpha and median intercriterion correlations (MIC). Cronbach's alpha ranged from 0.47 to 0.87 (median=0.71); seven of the 10 PDs had alphas greater than 0.70. Between-category criterion overlap was evaluated by "inter-category" intercriterion correlations between all PD pairs (ICMIC). ICMIC values (median=0.08) were lower than MIC values (median=0.23). Diagnostic efficiency statistics (sensitivity, specificity, positive predictive power and negative predictive power were calculated for schizotypal, borderline, avoidant and obsessive-compulsive PDs.

CONCLUSION

DSM-IV PD criteria sets have some convergent validity and discriminant validity: criteria for individual PDs correlate better with each other than with criteria for other PDs. Diagnostic efficiency statistics provide guidance regarding usefulness of criteria for inclusion or exclusion.

Use of structured self-report assessment to diagnose borderline personality disorder during major depressive episodes

Diagnosis of borderline personality disorder (BPD) during episodes of major depression (MDE), although clinically important, is complicated in several respects when using self-report methods. Structured interview data were used to select a group of patients with comorbid BPD (n=21) from a sample of outpatients presenting with MDE. This group was compared with a group of MDE patients without BPD (n=24) and with a group of community controls (n=20) using self-report data from the Personality Assessment Inventory (PAI), the revised Personality Diagnostic Questionnaire (PDQ), and the Beck Depression Inventory (BDI). Analyses revealed that the BPD group obtained significantly higher scores on PAI and PDQ scales measuring features of BPD and on the PAI Negative Impression Management scale. The severity and type of MDE symptoms reported on the PAI and BDI did not differentiate the clinical groups. These data show that useful information for the diagnosis of BPD during depressive episodes can be gathered from self-report assessment instruments like the PAI.

The Collaborative Longitudinal Personality Disorders Study: reliability of axis I and II diagnoses

Both the interrater and test-retest-retest reliability of axis I and axis II disorders were assessed using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and the Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV). Fair-good median interrater kappa (.40-.75) were found for all axis II disorders diagnosed five times or more, except antisocial personality disorder (1.0). All of the test-retest kappa for axis II disorders, except for narcissistic personality disorder (1.0) and paranoid personality disorder (.39), were also found to be fair-good. Interrater and test-retest dimensional reliability figures for axis II were generally higher than those for their categorical counterparts; most were in the excellent range (> .75). In terms of axis I, excellent median interrater kappa were found for six of the 10 disorders diagnosed five times or more, whereas fair-good median interrater kappa were found for the other four axis I disorders. In general, test-retest reliability figures for axis I disorders were somewhat lower than the interrater reliability figures. Three test-retest kappa were in the excellent range, six were in the fair-good range, and one (for dysthymia) was in the poor range (.35). Taken together, the results of this study suggest that both axis I and axis II disorders can be diagnosed reliably when using appropriate semistructured interviews. They also suggest that the reliability of axis II disorders is roughly equivalent to that reliability found for most axis I disorders.

The Collaborative Longitudinal Personality Disorders Study: development, aims, design, and sample characteristics

This paper describes the aims, background, design, and methods used in a collaborative longitudinal study of Axis II personality disorders (PDs). This study examines the putative stability of selected PD diagnoses and criteria, what factors affect their course, and whether their stability and course distinguishes them from a representative Axis I disorder. This article also describes the acquisition and demographics of the sample on whom the study is being done. A prospective, repeated measures investigation of the stability of PDs is now underway at multiple clinical settings in four collaborating urban sites in Boston. New Haven, New York, and Providence. Diagnostic assignments are based on semistructured interview assessments (by clinically trained raters) and confirmed by at least one additional contrasting diagnostic method. The sample consists of 668 treatment seeking and reliably diagnosed adults recruited from a broad range of clinical sites. By design, patients in the sample met standards for one of five diagnostic subgroups: (a) schizotypal (N = 86); (b) borderline (N = 175); (c) avoidant (N = 157); (d) obsessive-compulsive (N = 153) personality disorders or a control group having (e) major depressive disorder without personality disorder (N = 97).

Borderline personality: traits and disorder

Although the 5-factor model (FFM) has been advocated as an alternative to representing the construct of borderline personality, some argue that this diagnosis carries essential information that is not well captured by the FFM. The present study examined antecedent, concurrent, and predictive markers of construct validity in a sample of 362 patients with personality disorders. The results indicated that neuroticism best distinguished borderline and nonborderline patients, whereas the FFM as a whole captured a sizable proportion of the variance in the borderline diagnosis. However, the residual of the borderline diagnosis that was not explained by the FFM was found to be significantly related to childhood abuse history, family history of mood and substance use disorders, concurrent symptoms, and 2-year and 4-year outcomes. Thus, some elements of the borderline diagnosis may not be fully captured in a 5-factor representation.

Borderline personality: traits and disorder

Although the 5-factor model (FFM) has been advocated as an alternative to representing the construct of borderline personality, some argue that this diagnosis carries essential information that is not well captured by the FFM. The present study examined antecedent, concurrent, and predictive markers of construct validity in a sample of 362 patients with personality disorders. The results indicated that neuroticism best distinguished borderline and nonborderline patients, whereas the FFM as a whole captured a sizable proportion of the variance in the borderline diagnosis. However, the residual of the borderline diagnosis that was not explained by the FFM was found to be significantly related to childhood abuse history, family history of mood and substance use disorders, concurrent symptoms, and 2-year and 4-year outcomes. Thus, some elements of the borderline diagnosis may not be fully captured in a 5-factor representation.

The Collaborative Longitudinal Personality Disorders Study: baseline Axis I/II and II/II diagnostic co-occurrence

OBJECTIVE

To describe baseline diagnostic co-occurrence in the Collaborative Longitudinal Personality Disorders Study.

METHOD

Six hundred and sixty-eight patients were reliably assessed with diagnostic interviews for DSM-IV Axis I and II disorders to create five groups: Schizotypal (STPD), Borderline (BPD), Avoidant (AVPD), Obsessive-Compulsive (OCPD) and Major Depressive Disorder (MDD) without personality disorder (PD).

RESULTS

Mean number of Axis I lifetime diagnoses was 3.4; STPD and BPD groups had more diagnoses than AVPD, OCPD, and MDD groups. Significant Axis I co-occurrences emerged for Social Phobia/ AVPD, PTSD/BPD and Substance Use/BPD. Mean number of co-occurring PDs was 1.4; STPD had more than BPD group which had more than AVPD and OCPD groups. Significant PD co-occurrence emerged for: STPD/ Paranoid and Schizoid PDs, BPD with Antisocial and Dependent PDs, and lower frequency for OCPD/Antisocial PD.

CONCLUSION

Diagnostic co-occurrences generally followed base rates, while significant departures resemble those of controlled literature.

Dimensions and categories: the "big five" factors and the DSM personality disorders

The five-factor model of personality, which has been widely studied in personality psychology, has been hypothesized to have specific relevance for DSM-defined personality disorders. To evaluate hypothesized relationships of the five-factor model of personality to personality disorders, 144 patients with personality disorders (diagnosed via a structured interview) completed an inventory to assess the five-factor model. Results indicated that the majority of the personality disorders can be differentiated in theoretically predictable ways using the five-factor model of personality. However, while the personality disorders as a whole appear to be differentiable from normal personality functioning on the five factors, the patterns are quite similar across the disorders, a finding that may provide some insight into the general nature of personality pathology but may also suggest problems with discriminant validity. Third, it does not appear that considering disorders as special combinations of features (as might be expected in some categorical models) is more informative than considering them as the sum of certain features (as might be expected in a dimensional model).

Co-occurrence of mood and personality disorders: a report from the Collaborative Longitudinal Personality Disorders Study (CLPS)

The purpose of this study was to examine the relationship of subtypes and particular clinical features of mood disorders to co-occurrence with specific personality disorders. Five hundred and seventy-one subjects recruited for the Collaborative Longitudinal Personality Disorders Study (CLPS) were assessed with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and the Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV). Percent co-occurrence rates for current and lifetime mood disorders with personality disorders were calculated. Logistic regression analyses examined the effects of clinical characteristics of depressive disorders (e.g., age at onset, recurrence, symptom severity, double depression, and atypical features) on personality disorder co-occurrence. In comparison with other DSM-IV personality disorders, avoidant, borderline, and dependent personality disorders (PDs) were most specifically associated with mood disorders, particularly depressive disorders. Severity and recurrence of major depressive disorder and comorbid dysthymic disorder predicted co-occurrence with borderline and to a lesser extent research criteria depressive personality disorders. The results are consistent with the view that a mood disorder with an insidious onset and recurrence, chronicity, and progression in severity leads to a personality disorder diagnosis in young adults.

Applicability of personality disorder criteria to hospitalized adolescents: evaluation of internal consistency and criterion overlap

OBJECTIVE

The authors examined the applicability of personality disorder criteria to adolescent inpatients by evaluating internal consistency and criterion overlap.

METHOD

Thirty-eight adolescents and 28 adults were assessed with the Personality Disorder Examination. Within-category cohesiveness (internal consistency) of the criteria was evaluated by examining intercriterion correlations as well as coefficient alpha. In addition, between-category criterion overlap was evaluated by examining "intercategory" intercriterion correlations between all pairs of disorders. Separate analyses were conducted for adolescents and adults, and the groups were compared.

RESULTS

Internal consistency appeared to be lower in adolescents, as measured by intercriterion correlation and coefficient alpha, with the largest differences being identified for most cluster B disorders. Intercategory analysis indicated that criterion overlap may be greater among adolescents.

CONCLUSIONS

Overall, this psychometric analysis suggests that there may be limitations to the DSMs approach to categorizing personality disorders. For both adolescents and adults, modest degrees of within-category cohesiveness (internal consistency) and between-category criterion overlap were observed. Comparatively, personality disorder criteria in adolescents tended to have lower internal consistency and less discriminant validity. The data raise questions about the construct validity of these disorders--or the applicability of these criteria--within this age group.

Negativism in evaluative judgments of words among depressed outpatients with borderline personality disorder

This study contrasted the frequency of negativistic evaluative judgments to words of various emotional content between two groups of patients with Major Depressive Disorder (MDD) (20 patients with a comorbid diagnosis of Borderline Personality Disorder (BPD) and 20 patients without BPD) and a group of 20 community adult Controls. BPD patients made more "dislike" judgments with neutral words than MDD patients and Controls. The performances of the MDD patients were more similar to the Control group than to the BPD group, despite negligible differences between the two patient groups in the severity of depressive symptoms and overall psychopathology. As a whole, these data indicate that the presence of borderline features in patients with MDD can be an important qualifier in terms of patients attitudinal dispositions.

Passive-aggressive personality disorder: the demise of a syndrome

This article presents an explanation and critique of the rationale for dropping passive-aggressive personality disorder (PAPD) from DSM-IV. The clinical and research literature on PAPD is reviewed along with the historical changes in definition, diagnostic criteria, and usage. PAPD can be reliably diagnosed, is fairly prevalent, and has good internal consistency. Because PAPD is no less valid than other personality disorders, and describes clinical phenomena that are unique among personality disorders, we recommend the reinstatement of PAPD in the official diagnostic nomenclature.

Operating characteristics of six response distortion indicators for the personality assessment inventory

The characteristics of six different indicators of response distortion on the Personality Assessment Inventory (PAI; Morey, 1991) were evaluated by having college students complete the PAI under positive impression management, malingering, and honest responding conditions. The six indicators were the PAI Positive Impression (PIM) and Negative Impression (NIM) scales, the Malingering and Defensiveness Indexes, and two discriminant functions, one developed by Cashel and the other by Rogers. Protocols of students asked to malinger were compared with those of actual clinical patients, while protocols of students asked to manage their impression in a positive direction were compared with those of students asked to respond honestly. Comparisons between groups were accomplished through the examination of effect sizes and receiver operating characteristic (ROC) curves. All six indicators demonstrated the ability to distinguish between actual and feigned responding. The Rogers function was particularly effective in identifying malingering. The Cashel function was less effective than other measures in identifying positive impression management, although it appears to also have promise as an indicator of malingering.

Detection of feigned mental disorders on the personality assessment inventory: a discriminant analysis

Psychological assessment with multiscale inventories is largely dependent on the honesty and forthrightness of those persons evaluated. We investigated the effectiveness of the Personality Assessment Inventory (PAI) in detecting participants feigning three specific disorders: schizophrenia, major depression, and generalized anxiety disorder. With a simulation design, we tested the PAI validity scales on 166 naive (undergraduates with minimal preparation) and 80 sophisticated (doctoral psychology students with 1 week preparation) participants. We compared their results to persons with the designated disorders: schizophrenia (n = 45), major depression (n = 136), and generalized anxiety disorder (n = 40). Although moderately effective with naive simulators, the validity scales evidenced only modest positive predictive power with their sophisticated counterparts. Therefore, we performed a two-stage discriminant analysis that yielded a moderately high hit rate (> 80%) that was maintained in the cross-validation sample, irrespective of the feigned disorder or the sophistication of the simulators.

The MMPI/MMPI-2 Personality Disorder scales: contemporary norms for adults and adolescents

Eleven personality disorder scales for the MMPI, as described in DSM-III, were derived by Morey and his colleagues from the original MMPI item pool through a combination of rational and empirical strategies. These new scales have enjoyed popularity among clinicians. Normative tables for each of these scales, with and without overlapping items, were constructed from MMPI responses from a large contemporary normal reference sample of adults and adolescents without any physical or mental handicaps who were selected randomly from a three-state area in the Midwest. Some items from the Morey Personality Disorder scales were deleted during development of the MMPI-2; separate normative tables have been prepared for the scales so affected, which allows clinicians who are using the MMPI-2 to continue to use these slightly modified scales.

Early manifestations of dementing illness: treatment with glycosaminoglycan polysulfate

1. In a multicenter, placebo-controlled, double-blind clinical trial in 156 elderly patients with psychopathologic symptoms, glycosaminoglycan polysulfate was found to be a therapeutically effective agent in the treatment of the earliest manifestations of a dementing process. 2. Treatment with glycosaminoglycan polysulfate in the daily dosage of 600 LRU, administered on the basis of a divided dosage schedule for 24 weeks, was significantly superior to an inactive placebo on several outcome measures including the SCAG Total and factor scores (i.e., Cognitive Dysfunction, Withdrawal, Agitation/Irritability and Depression), the NOWLIS Total and Fatiguability factor scores, the MMSE, the HAM-D Total and Vegetative Symptoms factor score and the CGI Severity of Illness and Global Improvement. 3. The drug was well tolerated; vital signs and laboratory measures did not show clinically significant changes within the experimental period.

Classification of mental disorder as a collection of hypothetical constructs

In this article, I explore the implications of viewing psychiatric classification as a collection of hypothetical constructs. In this view, a taxonomic construct includes meaning surplus to the descriptive features provided by operational definitions, such as those provided in the American Psychiatric Association's 4th edition of the Diagnostic and Statistical Manual of Mental Disorders. This surplus meaning includes ties to etiology and treatment that for many disorders are as yet unknown. Despite these unknowns, it is proposed that a taxonomic construct must be embedded in a theory that provides some meaningful context for the construct and that falsification of such theories constitutes the primary enterprise of taxonomic research.

Classification of mental disorder as a collection of hypothetical constructs

In this article, I explore the implications of viewing psychiatric classification as a collection of hypothetical constructs. In this view, a taxonomic construct includes meaning surplus to the descriptive features provided by operational definitions, such as those provided in the American Psychiatric Association's 4th edition of the Diagnostic and Statistical Manual of Mental Disorders. This surplus meaning includes ties to etiology and treatment that for many disorders are as yet unknown. Despite these unknowns, it is proposed that a taxonomic construct must be embedded in a theory that provides some meaningful context for the construct and that falsification of such theories constitutes the primary enterprise of taxonomic research.

Glycosaminoglycan polysulfate in the treatment of old age dementias

1. In a multicenter, placebo-controlled, double-blind clinical trial in 155 elderly patients with cognitive decline, glycosaminoglycan polysulfate was found to be a therapeutically effective agent in the treatment of old age dementias. 2. Treatment with glycosaminoglycan polysulfate in the daily dosage of 600 LRU, administered on the basis of a divided dosage schedule for 12 weeks, was significantly superior to an inactive placebo on several outcome measures including the Wechsler Memory Scale-Russell Revision (Easy Paired Associates Learning and Immediate Visual Reproduction), Mini Mental State Examination, the Sandoz Clinical Assessment Geriatric (Cognitive Dysfunction and Depression), Hachinski Dementia Scale, Brief Psychiatric Rating Scale (Confusion and Depressive Withdrawal) and Global Improvement Scale of the Clinical Global Impression. 3. Adverse effects with glycosaminoglycan polysulfate were few and mild. The drug was equally well tolerated and equally effective in the two major dementias of old age, i.e., primary degenerative and multi-infarct. The number of abnormal laboratory test readings remained essentially unchanged from pre-treatment to post-treatment.

Matchmaking in psychotherapy: patient-therapist dimensions and their impact on outcome

Patient-therapist matching was investigated using recent theoretical and methodological developments to overcome some of the limitations that have hindered similar past efforts. Two hypotheses were tested: (a) Therapeutic outcome is affected by the interaction between patients' and therapists' self-concepts, and (b) increasing anticomplementarity between therapist self-concept and therapists' perceptions of patients' behavior is negatively associated with patient improvement. Data from the first 2 cohorts of the Vanderbilt II Psychotherapy Project were analyzed. They included the therapies of 16 experienced therapists, who saw a total of 48 patients (38 women and 10 men) in time-limited psychotherapy. Patients' ages ranged from 24 to 64 years (M age = 40). Outcome was measured from the perspective of the patient, therapist, and evaluating clinician. Each hypothesis was supported, but not across all 3 outcome perspectives.

Reliability of categorical and dimensional judgments of personality disorder

To investigate interrater reliability on categorical and dimensional judgments of personality disorder, five clinicians completed five different judgment tasks for each of 10 case vignettes. The reliability estimates support previously unconfirmed statements that dimensional judgments are substantially more reliable than categorical diagnoses.

Heterogeneity of personality traits in massive obesity and outcome prediction of bariatric surgery

The search for heterogeneity of personality characteristics amongst the massively obese is extended to a larger sample (n = 215) of both males (n = 83) and females (n = 132). The Minnesota Multiphasic Personality Inventory standard scales serve as the data base for a cluster analysis which has yielded four clusters: cluster 1 (n = 36) where all scales fell well within normal limits; cluster 2 (n = 112) was coded as 3-1 and was also within normal limits; cluster 3 (n = 44) was coded as spike 4; and cluster 4 (n = 23) was coded as 2-1-7-3-8-4. Cluster membership was not related to surgeons' four-year follow-up overall outcome rating. Discriminant function analysis yielded two variables (patient age and MMPI scale 1 T-score) which were significant predictors of subsequent outcome. The results suggest that there is heterogeneity of personality traits among the massively obese and offer encouragement to the search for variables that are even more effective predictors of the outcome of bariatric surgery.

Matchmaking in psychotherapy: Patient-therapist dimensions and their impact on outcome

Patient-therapist matching was investigated using recent theoretical and methodological developments to overcome some of the limitations that have hindered similar past efforts. Two hypotheses were tested: (a) Therapeutic outcome is affected by the interaction between patients' and therapists' self-concepts, and (b) increasing anticomplementarity between therapist self-concept and therapists' perceptions of patients' behavior is negatively associated with patient improvement. Data from the first 2 cohorts of the Vanderbilt II Psychotherapy Project were analyzed. They included the therapies of 16 experienced therapists, who saw a total of 48 patients (38 women and 10 men) in time-limited psychotherapy. Patients' ages ranged from 24 to 64 years (M age = 40). Outcome was measured from the perspective of the patient, therapist, and evaluating clinician. Each hypothesis was supported, but not across all 3 outcome perspectives.

Glycosaminoglycan polysulfate (Ateroid) in old-age dementias: effects upon depressive symptomatology in geriatric patients

1. Glycosaminoglycan polysulfate is a mixture of sulfo-muco-polysaccharides with hypolipidemic activity. A number of clinical studies have indicated that it is effective in improving psychopathology in patients with cardiac and/or cerebral disease associated with arteriosclerosis. 2. A multicenter clinical trial was performed to compare the effects of two different dosages of glycosaminoglycan polysulfate upon depressive symptomatology in patients with multi-infarct dementia and primary degenerative dementia. 3. A total of 39 patients were treated in an 18-week clinical trial which followed a single-blind parallel design. 4. Results indicated that patients with both diagnoses improved significantly in depressive symptomatology over the course of treatment, with particular improvement noted in cognitive disturbance. Drug dosage was not a significant determinant of treatment response for either diagnostic group.

Personality disorders in DSM-III and DSM-III-R: convergence, coverage, and internal consistency

Although many sections of DSM-III-R reflect few changes from DSM-III, the diagnostic criteria for the personality disorders involve more substantial revisions. This study examined the impact of DSM-III-R revisions in terms of convergence with DSM-III, the diagnostic coverage of patients with personality disorders, and the internal consistency of the personality disorder criteria sets. The results demonstrated a substantial divergence between DSM-III and DSM-III-R diagnoses, increased coverage accompanied by a large increase in overlap among personality disorders, and internal consistency estimates of DSM-III-R criterion sets comparable to those in DSM-III.

MMPI scales for DSM-III personality disorders: a preliminary validation study

A preliminary investigation of the external validity of MMPI scales designed to measure certain DSM-III Personality disorders (N = 108) is reported. Results indicate that many of these scales are effective for discriminating clinically diagnosed personality disorders from control subjects (N = 640).

Glycosaminoglycan polysulfate in old-age dementias: a factor-analytic study of change in psychopathologic symptoms

In a multicenter clinical trial, two dosages of glycosaminoglycan polysulfate were compared in patients with primary degenerative dementia and multi-infarct dementia. Psychopathologic symptoms were assessed using the Brief Psychiatric Rating Scale (BPRS). A factor analysis of this scale revealed four factors in this population. During the clinical trial, significant improvements were noted on the primary BPRS factor (i.e. depressive withdrawal), as well as on total BPRS score. There was a tendency for greater improvement in the primary degenerative dementia group than in the multi-infarct dementia group.

Empirically derived classifications of alcohol-related problems

In recent years a number of investigators have utilized empirical techniques to develop classification schemes for alcohol related problems. This chapter examines this literature, reviewing both dimensional and categorical models that have been proposed. Despite much consistency in the methodologies that have been used, relatively few consistent substantive findings have emerged from these studies. However, increasing sophistication in the use of these empirical techniques over the past decade has produced some interesting results. One such study which yielded a hybrid model for alcoholism incorporating advantages of both categorical and dimensional approaches, is discussed in some detail. Finally, promising directions for future research are outlined with references to the implications of such taxonomy for alcoholism treatment and course.

An empirical comparison of interpersonal and DSM-III approaches to classification of personality disorders

In recent years, a number of authors have attempted to map correspondences between interpersonal models and traditional psychiatric classification. Many of the proposed relationships are plausible from a theoretical standpoint, but at present little empirical evidence has been gathered in support of these speculations. This paper describes the results of a project that suggests that the convergence of these two approaches to personality taxonomy is not as high as might be expected. In particular, it seems that DSM-III personality disorders are not as differentiated with respect to affiliative needs as has been hypothesized.

MMPI scales for DSM-III personality disorders: their derivation and correlates

Scales tapping the dimensions of personality disorder as represented in the DSM-III were derived using a combined rational/empirical strategy. The final version of the scales demonstrated both content validity as well as internal consistency. Correlations between the derived scales and between these scales and the original MMPI clinical scales were generally found to be in the expected direction providing preliminary evidence of criterion related validity. It is suggested that the derived scales may represent an advance toward the reliable assessment of DSM-III personality constructs.

A comparative validation of the Foulds and Bedford hierarchy of psychiatric symptomatology

This study investigated the validity of the Fould & Bedford hierarchical model of psychiatric illness, as compared to hierarchical models based upon prevalence and severity of disorder. The DSSI was administered to 52 American psychiatric in-patients with severe disturbances. The reports of symptoms in this sample conformed to the Foulds hierarchy in 90% of cases, while 94% of cases conformed to a model based upon prevalence. When a cross-method validation was investigated, the Foulds & Bedford classification demonstrated good discriminative capacity, while models based upon prevalence and severity failed to achieve significance. These results suggest that the Foulds & Bedford model is a useful taxonomy of symptomatology in psychiatric illness.

A Comparison of Cluster Analysis Techniques Withing a Sequential Validation Framework

This study involved the comparison of 23 different methods of cluster analysis in a four-stage sequential validation design. These stages included derivation, replication, external validation, and cross-validation. Data were obtained from 750 alcohol abusers on a number of socio-behavioral variables. Results demonstrated that the solution given by Ward's method of cluster analysis was particularly powerful in comparison to solutions yielded by other techniques.

An Adjustment for Protocol Length in Rorschach Scoring

A procedure is proposed by which the comparison of Rorschach protocols is facilitated through separation of the artifact of protocol length. This procedure may help empirical investigation of the Rorschach by standardization with respect to both group norms and profile elevation, similar to the method proposed by Skinner (1978) for use with the MMPI.