A comparison of self-report and interview diagnoses of DSM-III-R personality disorders

A total of 73 psychiatric inpatients, all of whom (but two) fulfilled criteria for at least one specific personality disorder (PD) on SCID-II PQ, were interviewed with the help of PDE. The self-report PD diagnosis was confirmed in 35 (48 per cent) patients. The diagnostic agreement between the two instruments was poor, yielding an overall weighted kappa of 0.22. Levelling off the PD base rates by increasing or decreasing the diagnostic threshold of SCID-II PQ and PDE respectively increased the overall weighted kappa to 0.38 in both instances. 70 per cent of SCID-II PQ but only 29 per cent of PDE personality disorders were of extensive type. Most frequent important co-occurrences occurred between individual PD types within cluster 2. On the whole, the results confirmed the relatively poor agreement between self-report and interview PD diagnoses. The utilization of self-report questionnaires in a clinical practice remains a controversial issue. © 1998 John Wiley & Sons, Ltd.     

Assessment of eating disorder psychopathology in obese children and adolescents: interview versus self-report questionnaire

The present study compared two methods for assessing binge eating and related eating disorder psychopathology in obese children and adolescents. A comparison was made between the child version of the Eating Disorder Examination (ChEDE) and the self-report version of the interview (ChEDE-Q). A total of 139 children and adolescents (aged 10-16 years) seeking inpatient treatment for obesity completed the ChEDE questionnaire and were administered the ChEDE interview afterwards. The ChEDE and ChEDE-Q were significantly correlated for the four subscales: restraint, eating concern, weight concern and shape concern. The ChEDE-Q generated consistently higher levels of eating disorder psychopathology. There was a significant discrepancy for the assessment of a more complex feature such as binge eating. Overall, the current study found lower levels of agreement between the EDE and EDE-Q than previously reported in adult samples. It appears that children and adolescents have difficulties in identifying binge-eating episodes when they receive no detailed instruction. It is concluded that a clinical interview is necessary to identify eating disorders in obese children and that a self-report questionnaire can only be used as a screening tool. Even then, thorough clarification of the definition of the eating disorder features is needed when using a self-report questionnaire.     

A comparison of interview and self-report methods for the assessment of borderline personality disorder criteria

Interview methods are widely regarded as the standard for the diagnosis of borderline personality disorder (BPD), whereas self-report methods are considered a time-efficient alternative. However, the relative validity of these methods has not been sufficiently tested. The current study used data from the Collaborative Longitudinal Personality disorder Study to compare diagnostic base rates and the relative validity of interview and self-report methods for assessing functional outcome in BPD. Although self-report yielded higher base rates of criteria endorsement, results did not support the common assumption that diagnostic interviews are more valid than self-reports, but instead indicated the combined use of these methods optimally identifies BPD criteria.     

Comparing the temporal stability of self-report and interview assessed personality disorder

Findings from several large-scale, longitudinal studies over the last decade have challenged the long-held assumption that personality disorders (PDs) are stable and enduring. However, the findings, including those from the Collaborative Longitudinal Personality Disorders Study (CLPS; Gunderson et al., 2000), rely primarily on results from semistructured interviews. As a result, less is known about the stability of PD scores from self-report questionnaires, which differ from interviews in important ways (e.g., source of the ratings, item development, and instrument length) that might increase temporal stability. The current study directly compared the stability of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) PD constructs assessed via the Schedule for Nonadaptive and Adaptive Personality (SNAP-2; Clark, Simms, Wu, & Casillas, in press) with those from the Diagnostic Interview for DSM-IV Personality Disorders (Zanarini, Frankenburg, Sickel, & Yong, 1996) over 2 years in a sample of 529 CLPS participants. Specifically, we compared dimensional and categorical representations from both measures in terms of rank-order and mean-level stability. Results indicated that the dimensional scores from the self-report questionnaire had significantly greater rank-order (mean r=.69 vs. .59) and mean-level (mean d=0.21 vs. 0.30) stability. In contrast, categorical diagnoses from the two measures evinced comparable rank-order (mean κ=.38 vs. .37) and mean-level stability (median prevalence rate decrease of 3.5% vs. 5.6%). These findings suggest the stability of PD constructs depends at least partially on the method of assessment and are discussed in the context of previous research and future conceptualizations of personality pathology.     

Opinions of personality disorder experts regarding the DSM-IV personality disorders classification system

OBJECTIVE: To survey the opinions of personality disorder (PD) experts on possible revisions in the classification system for PDs in the DSM-V. METHOD: Four hundred members of two international associations, the Association for Research on Personality Disorders, and the International Society for the Study of Personality Disorders, were asked to take a 78-item web survey. RESULTS: Of the experts who completed the survey (N = 96), 74% felt that the DSM-IV's categorical system of PD diagnosis should be replaced. Eighty percent felt that PDs are better conceived of as personality dimensions or illness spectra, than as categories. The most frequently endorsed alternative system for PDs was a mixed system of categories and dimensions. Most experts preferred the PDs to remain on Axis II. Only 31.3% wanted the term, "Borderline Personality Disorder," retained in the DSM-V. CONCLUSIONS: A clear majority of the PD experts were dissatisfied with the current diagnostic system for PDs.     

Beliefs in personality disorders: a test with the personality disorder belief questionnaire

The hypothesis that each personality disorder (PD) is characterized by a specific set of beliefs was tested in a sample of 643 subjects, including non-patient controls, axis-I and axis-II patients, diagnosed with SCID-I and -II interviews. Beliefs of six PDs (avoidant, dependent, obsessive-compulsive, paranoid, histrionic, borderline) were assessed with the Personality Disorder Belief Questionnaire (PDBQ). Factor analyses supported the existence of six hypothesized sets of beliefs. Structural equation modeling (SEM) supported the hypothesis that each PD is characterized by a specific set of beliefs. Path coefficients were however in the medium range, suggesting that PDs are not solely determined by beliefs. Nevertheless, empirically derived cutoff scores of the six belief subscales were reasonably successful in classifying subjects, percentages ranging form 51% to 83%. It appeared that there was a monotonical increase in scores on each belief subscale from non-patient controls, to patients without any PD, to patients with PDs (other than the pertinent PD), to patients with the pertinent PD. This suggests that PD-related beliefs are at least partly associated with (personality) psychopathology in general. Another explanation is that many patients' position on the underlying dimensions is not high enough to lead to a DSM PD diagnosis, but high enough to lead to an elevated belief score.     

The ADP-IV questionnaire: differential validity and concordance with the semi-structured interview

The Assessment of DSM-IV Personality Disorders questionnaire (ADP-IV) is a self-report measure of the DSM-IV Axis II personality disorders (PDs). The ADP-IV assesses for each DSM-IV criterion its typicality as well as the accompanying distress and impairment. This study investigates two important aspects of the construct validity of the ADP-IV: (a) the differential validity (i.e., the ability to differentiate between a sample of the general Flemish population ( n = 659) and a sample of psychiatric inpatients ( n = 487) with a high prevalence of clinical PD diagnoses, and patients with and without a PD in the psychiatric sample; (b) the convergent validity with the SCID-II semi-structured interview in a population of psychiatric inpatients ( n = 59). The results indicate a good differential validity: the dimensional scales and the categorical measures discriminated well between both groups and between patients with and without a PD diagnosis in the psychiatric sample. Concerning the concordance with the SCID-II, a decent level of agreement is exemplified by a correlation of.67 between the dimensional total scores of both instruments and by kappa coefficients for an "any" Axis II diagnosis at the.50 level. In conclusion, the results indicate that the ADP-IV is an efficient method for assessing PD in dimensional and categorical ways.     

Genetic and environmental contributions to the co-occurrence of depressive personality disorder and DSM-IV personality disorders

One of the main controversies with regard to depressive personality disorder (DPD) concerns the co-occurrence with the established DSM-IV personality disorders (PDs). The main aim of this study was to examine to what extent DPD and the DSM-IV PDs share genetic and environmental risk factors, using multivariate twin modeling. The DSM-IV Structured Interview for Personality was applied to 2,794 young adult twins. Paranoid PD from Cluster A, borderline PD from Cluster B, and all three PDs from Cluster C were independently and significantly associated with DPD in multiple regression analysis. The genetic correlations between DPD and the other PDs were strong (.53-.83), while the environmental correlations were moderate (.36-.40). Close to 50% of the total variance in DPD was disorder specific. However, only 5% was due to disorder-specific genetic factors, indicating that a substantial part of the genetic vulnerability to DPD also increases the vulnerability to other PDs.     

Rates of personality disorders in substance abusers: a comparison between DSM-III-R and DSM-IV

The publication of the DSM-IV represents the first revision in 7 years to the DSM-III-R diagnostic criteria. The purpose of the current study is to evaluate the impact of changes to the Axis II criteria on diagnostic rates in a substance abusing population. We interviewed 370 patients entering treatment using a modified version of the SCID-II, which allowed for the diagnosis of both DSM-III-R and DSM-IV Axis II diagnoses. Prevalence rates for each Axis II disorder are given, as well as kappa statistics showing diagnostic agreement between the two systems. The results of this study indicate good rates of diagnostic agreement between the two systems with a few notable exceptions. Poor rates of diagnostic agreement were obtained for the histrionic and dependent diagnostic categories. No single diagnostic change appears to be responsible for the prevalence rate differences between the two systems.     

Pattern of comorbidity among anxious and odd personality disorders: the case of obsessive-compulsive personality disorder

The aim of this study was to examine the pattern of comorbidity among obsessive-compulsive personality disorder (OCPD) and other personality disorders (PDs) in a sample of 400 psychiatric inpatients. PDs were assessed using the Semistructured Clinical Interview for DSM-III-R Personality Disorders (SCID-II). Odds ratios (ORs) were calculated to determine significant comorbidity among OCPD and other axis II disorders. The most elevated odds ratios were found for the cooccurrence of OCPD with cluster A PDs (the "odd" PDs, or paranoid and schizoid PDs). These results are consistent with those of previous studies showing a higher cooccurrence of OCPD with cluster A than with cluster C ("anxious") PDs. In light of these observations, issues associated with the nosologic status of OCPD within the Diagnostic and Statistical Manual of Mental Disorders clustering system remain unsettled.     

Dimensions of DSM-IV personality disorders and life-success

This study examined associations between dimensional representations of DSM-IV personality disorders and life-success in a community sample of 304 men at age 48. Measures included a standardized social interview and the SCID-II for assessment of personality disorders. The identified indicators of life-success were factor-analyzed resulting in two moderately correlated components representing "status and wealth" and "successful intimate relationships." Avoidant, obsessivecompulsive, and narcissistic dimensional scores were positively associated with "status and wealth." Inverse relationships were found between dependent, schizotypal, schizoid, and adult antisocial personality disorder dimensions and this domain of life-success. Avoidant, schizoid, and borderline personality disorder dimensions were negatively associated with "successful intimate relationships." The findings suggest that although most personality disorders are associated with impaired psychosocial functioning and life-failure, some personality disorder traits (even if considered as pathological) can contribute positively to one important aspect of life-success: status and wealth.     

A comparison of the validity of the five-factor model (FFM) personality disorder prototypes. Using FFM self-report and interview measures

Recent studies have demonstrated that personality disorders (PDs) can be assessed via a prototype-matching technique, which enables researchers and clinicians to match an individual's five-factor model (FFM) personality profile to an expert-generated prototype. The current study examined the relations between these prototype scores, using interview and self-report data, and PD symptoms in an outpatient sample (N = 115). Both sets of PD prototype scores demonstrated significant convergent validity with PD symptom counts, suggesting that the FFM PD prototype scores are appropriate for use with both sources of data.     

Assessment procedures for narcissistic personality disorder: a comparison of the personality diagnostic questionnaire-4 and best-estimate clinical judgments

This study examined the degree of correspondence between two assessments for narcissistic personality disorder (NPD) in a mixed clinical and community sample--one using a self-report measure (Personality Diagnostic Questionnaire-4) and the other using clinical judgments derived from an assessment based on the longitudinal, expert, all data (LEAD) methodology. NPD scores demonstrated moderate convergence for the total scores but weak convergence for the individual criteria. The authors also examined the correlates created by each set of NPD scores using Cloninger's Temperament and Character Inventory (TCI). The NPD scores demonstrated areas of convergence (e.g., Cooperativeness, Self-directedness) and divergence (i.e., Harm Avoidance, Novelty Seeking) with these personality scores. These divergences may be due to the wording of certain items on the Personality Diagnostic Questionnaire-4 NPD scale, which may require rewriting if it is to provide an assessment that is more highly convergent with the Diagnostic and Statistical Manual of Mental Disorders NPD construct.     

Borderline and avoidant personality disorders and the five-factor model of personality: a comparison between DSM-IV diagnoses and NEO-PI-R.

A self-report measure of the Five-Factor Model (FFM) of personality, NEO-PI-R, was administered to a sample of patients with borderline (BPD, N = 29) or avoidant PD (AVPD, N = 34), admitted to a day treatment program, to investigate the NEO-PI-R profiles of the disorders, and the ability of NEO-PI-R to discriminate between the two disorders. The diagnoses were assessed according to the LEAD standard. AVPD was associated with high levels of Neuroticism and Agreeableness, and low levels of Extraversion and Conscientiousness. BPD was associated with high levels of Neuroticism and low levels of Agreeableness, Extraversion, and Conscientiousness. Eighty-eight percent of the AVPD group had high scores on Neuroticism and low scores on Extraversion, whereas 65% of the BPD group were high on Neuroticism and low on Agreeableness. The Extraversion and Agreeableness scales of NEO-PI-R discriminated between patients with BPD and those with AVPD. Patients with BPD scored significantly higher on the Angry Hostility and Impulsiveness subscales of Neuroticism and significantly lower on three Extraversion subscales, three Agreeableness subscales, and one Conscientiousness subscale. At the DSM-IV criterion level, there were more significant relationships between the subscales of NEO-PI-R and the AVPD criteria than with the BPD criteria. The findings suggest that the FFM has good discriminating ability regarding BPD and AVPD. However, there may be a closer conceptual relationship between the FFM and AVPD than between the FFM and BPD.     

Sex bias in the diagnosis of personality disorders: an evaluation of the DSM-IV criteria.

This study considered whether the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) is biased against women by requiring less dysfunction for the personality disorders that are more commonly diagnosed in women (e.g., histrionic). Clinicians estimated the extent of social dysfunction, occupational dysfunction, and personal distress suggested by each of the diagnostic criteria for 6 personality disorders. The results failed to suggest a bias against women, as there was no difference in the overall level of dysfunction associated with the female-typed personality disorder diagnostic criteria (fewer criteria are also required for the male-typed diagnoses). However, the considerable variation in dysfunction across disorders and criteria, and the minimal degree of impairment implied by some of the diagnostic criteria, also raise more general issues that should perhaps be addressed in future editions of the diagnostic manual.     

A comparison of clinical features in trichotillomania and obsessive-compulsive disorder.

Trichotillomania (TM) recently has been conceptualized as a variant of obsessive-compulsive disorder (OCD). However, no systematic data have compared the clinical features of these two disorders. Here we report data from 8 TM and 13 OCD patients which suggest important clinical differences between groups. First, TM patients reported a significantly greater degree of pleasure during hair-pulling than OCD patients reported during performance of ritualistic behaviors. Second, TM was accompanied by significantly fewer associated obsessive-compulsive symptoms. Third, the groups differed with regard to other clinical features including anxiety, depression, and personality characteristics. We conclude that TM is not conceptualized best as a variant of OCD.     

Dimensional personality profiles of borderline personality disorder in comparison with other personality disorders and healthy controls

The present study examined the sensitivity and clinical specificity of dimensional personality profiles associated with borderline personality disorder (BPD) by comparing three groups of patients: (a) patients with BPD according to DSM-IV criteria (n = 31); (b) patients with other DSM-IV PD (n = 31); and (c) general population controls (n = 31). All three samples were matched for age and gender and the two patient samples were matched for chronicity and depressive symptoms. All patients were given the Six-Factor Test measuring the five-factor model of personality (FFM), the Temperament and Character Inventory (TCI), and the Dimensional Assessment of Personality Pathology (DAPP). Nonparametric statistics were applied to analyze the data (Mann-Whitney-U-tests for group comparisons; Spearman's coefficients for correlational analyses). Neuroticism (FFM), Self-Directedness (TCI), and Emotional Dysregulation (DAPP) were identified as general markers of personality pathology, which were significantly interrelated in all three samples. BPD patients also showed a specific profile compared with other PD patients with lower scores on Agreeableness (FFM), higher scores on Novelty Seeking and Self-Transcendence (TCI), and higher scores on the DAPP higher-order dimensions of Emotional Dysregulation, Dissocial Behavior, and Inhibitedness. Results support the assumption that BPD can be characterized by dimensional approaches with sufficient sensitivity in comparison with healthy controls and specificity in comparison with other PD patients.     

Perfectionism in depression, obsessive-compulsive disorder and eating disorders

High levels of perfectionism have been observed in major depression, anxiety disorders and eating disorders. Though few studies have compared levels of perfectionism across these disorders, there is reason to believe that different dimensions of perfectionism may be involved in eating disorders than in depression or anxiety [Bardone-Cone, A. M. et al. (2007). Perfectionism and eating disorders: Current status and future directions. Clinical Psychology Review, 27, 84-405]. The present study compared patients with major depression, obsessive-compulsive disorder, and eating disorders on dimensions of perfectionism. Concern over Mistakes was elevated in each of the patient groups while Pure Personal Standards was only elevated in the eating disorder sample. Doubts about Actions was elevated in both patients with obsessive-compulsive disorder and eating disorders, but not in depressed patients. Analyses of covariance indicated that Concern over Mistakes accounted for most of the variance in the relationship of perfectionism to these forms of psychopathology.     

Influence of co-morbid generalized anxiety disorder, panic disorder and personality disorders on the outcome of cognitive behavioural treatment of obsessive-compulsive disorder

This study examined co-morbid generalized anxiety disorder and/or panic disorder and personality disorders as predictors of treatment outcomes in adult outpatients with obsessive-compulsive disorder. The patients received exposure with response prevention (ERP) treatment with the addition of either elements of cognitive therapy (ERP+CT) or relaxation training (ERP+REL). It was hypothesized that the addition of cognitive interventions would yield better treatment outcomes for patients with co-morbid generalized anxiety disorder and/or panic disorder. It was also hypothesized that patients with any personality disorder would show less treatment gains in both conditions. Using intention-to-treat criteria, patients with generalized anxiety disorder and/or panic disorder co-morbidity showed less treatment gains at post-treatment across both treatment conditions. This group showed significantly more treatment gains in the ERP+CT condition at the post-treatment and the 12-month follow-up assessments compared with patients in the ERP+REL condition. However, this was not significant when comparing treatment completers. Patients with a co-morbid Cluster A or B personality disorder showed significantly less treatment gains in both treatment conditions at the 12-month follow-up assessment. Among treatment completers, patients with a Cluster C personality disorder showed significantly better outcomes at the post-treatment assessment in the ERP+REL treatment condition. These results, clinical implications, and the importance of further investigations are discussed.     

Inferential confusion in obsessive-compulsive disorder: the inferential confusion questionnaire

The current article represents the further validation of the construct of inferential confusion amongst clinical samples. Inferential confusion is proposed to be a meta-cognitive confusion particularly relevant to obsessive compulsive disorder (OCD) that leads a person to confuse an imagined possibility with an actual probability. As such, it conceptualizes OCD as a form of belief disorder similar to a delusion or overvalued idea that is a product of distorted reasoning processes. In contrast, other cognitive models of OCD emphasize a phobic model of development in OCD, and thus consider the exaggerated interpretation of intrusions as an essential element in OCD. The present study administered a revised version of the Inferential Confusion Questionnaire, and the Obsessive Belief Questionnaire (OBQ), to a total of 183 participants in three clinical groups and a non-clinical control group. Results suggest that OCD, at least in part, follows a non-phobic model of development with inferential confusion significantly related to obsessive-compulsive symptoms independently of cognitive domains as measured by the OBQ, and mood states. Further, scores on inferential confusion were particularly high in those with OCD and delusional disorder as compared to anxious and non-clinical controls.