Integrating normal and abnormal personality structure: a proposal for DSM-V

The personality disorders section of the American Psychiatric Association's fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is currently being developed. The purpose of the current paper is to encourage the authors of DSM-V to integrate normal and abnormal personality structure within a common, integrative model, and to suggest that the optimal choice for such an integration would be the five-factor model (FFM) of general personality structure. A proposal for the classification of personality disorder from the perspective of the FFM is provided. Discussed as well are implications and issues associated with an FFM of personality disorder, including validity, coverage, feasibility, clinical utility, and treatment implications.     

Rethinking the mood and anxiety disorders: a quantitative hierarchical model for DSM-V

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) groups disorders into diagnostic classes on the basis of the subjective criterion of "shared phenomenological features." There are now sufficient data to eliminate this rational system and replace it with an empirically based structure that reflects the actual similarities among disorders. The existing structural evidence establishes that the mood and anxiety disorders should be collapsed together into an overarching class of emotional disorders, which can be decomposed into 3 subclasses: the bipolar disorders (bipolar I, bipolar II, cyclothymia), the distress disorders (major depression, dysthymic disorder, generalized anxiety disorder, posttraumatic stress disorder), and the fear disorders (panic disorder, agoraphobia, social phobia, specific phobia). The optimal placement of other syndromes (e.g., obsessive-compulsive disorder) needs to be clarified in future research.     

A prototype matching approach to diagnosing personality disorders: toward DSM-V

The current diagnostic system for personality disorders (PD) has a number of problems that may require a thorough revision for DSM-V. This article (a) outlines problems with the current taxonomy that suggest the need for a different approach to PD diagnosis that preserves the strengths of the current system while addressing some inherent weaknesses; (b) discusses key issues that must be addressed in moving toward DSM-V, such as revising the distinction between Axis I and Axis II and combining categorical and dimensional diagnosis; and (c) describes a prototype matching approach to diagnosis, which we believe has the potential to be both psychometrically sound and faithful to the clinical data.     

Personality disorders and the duration of depressive episode: a retrospective study

In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project we examined the relationship between chronicity of depression and personality disorders. Three hundred and eighty-five depressed outpatients were evaluated with semi-structured interviews. Duration of depression was analyzed as a continuous variable, and by subdividing patients by the DSM-IV (APA, 1994) chronic specifier (i.e., more or less than 2 years). Two separate regression analyses addressed the association between major depressive episode duration and each of the ten personality disorders found on Axis II. Although there was some difference between particular personality disorders associated with the two indicators of depressive duration, the results of the regression analyses indicate that the chronicity of depression is associated with personality disorders.     

Item response theory analysis of diagnostic criteria for alcohol and cannabis use disorders in adolescents: implications for DSM-V

Item response theory (IRT) has advantages over classical test theory in evaluating diagnostic criteria. In this study, the authors used IRT to characterize the psychometric properties of Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV; American Psychiatric Association, 1994) alcohol and cannabis use disorder symptoms among 472 clinical adolescents. For both substances, DSM-IV symptoms fit a model specifying a unidimensional latent trait of problem severity. Threshold (severity) parameters did not distinguish abuse and dependence symptoms. Abuse symptoms of legal problems and hazardous use, and dependence symptoms of tolerance, unsuccessful attempts to quit, and physical-psychological problems, showed relatively poor discrimination of problem severity. There were gender differences in thresholds for hazardous use, legal problems, and physical-psychological problems. The results illustrate limitations of DSM-IV criteria for alcohol and cannabis use disorders when applied to adolescents. The development process for the fifth edition (DSM-V) should be informed by statistical models such as those used in this study.     

Symptom dimensions in obsessive-compulsive disorder: implications for the DSM-V

In the absence of definitive etiological markers of vulnerability or a unitary profile of pathophysiology for obsessive-compulsive disorder (OCD), obsessive-compulsive (OC) symptom dimensions seem to offer a fruitful point of orientation. The complex clinical presentation of OCD can be summarized using a few consistent and temporally stable symptom dimensions. These can be understood as a spectrum of potentially overlapping features that are likely to be continuous with "normal" worries and extend beyond the traditional nosological boundaries of OCD. Although the understanding of the dimensional structure of obsessive-compulsive symptoms (OCS) is still imperfect, this quantitative approach to phenotypic traits has the potential to advance our understanding of OCD and may aid in the identification of more robust endophenotypes. Preliminary data suggest that these dimensional phenotypes may be useful in studies of the natural history, genetics, neurobiology, and treatment outcome of OCD. A dimensional approach is not mutually exclusive of other methods to parse the larger spectrum of disorders related to OCD. Thus far, age-of-onset of OCS and the individual's "tic-related" status seem to be particularly useful categorical distinctions. Finally, existing assessment methods are inadequate and new dimensional scales are needed to take full advantage of a dimensional approach in clinical and population-based studies.     

A proposal for a new system of credit allocation in science

This essay discusses some of the problems with current authorship practices and puts forward a proposal for a new system of credit allocation: in published works, scientists should more clearly define the responsibilities and contributions of members of research teams and should distinguish between different roles, such as author, statistican, technician, grant writer, data collector, and so forth. Dr. Resnik is an Associate Professor of Philosophy and Director of the Center for the Advancement of Ethics, University of Wyoming. Information is available on website: http://www.uwyo.edu/bu/acct/cae.htm     

Impaired self-reflection in psychiatric disorders among adults: A proposal for the existence of a network of semi independent functions

Self-reflection plays a key role in healthy human adaptation. Self-reflection might involve different capacities which may be impaired to different degrees relatively independently of one another. Variation in abilities for different forms of self-reflection are commonly seen as key aspects of many adult mental disorders. Yet little has been written about whether there are different kinds of deficits in self-reflection found in mental illness, how those deficits should be distinguished from one another and how to characterize the extent to which they are interrelated. We review clinical and experimental literature and suggest four different forms of deficits in self-reflection: (a) sense of ownership of one’s own thoughts and actions, (b) emotional awareness, (c) distinction between fantasy and reality and (d) the integration of a range of different views of oneself and others. We propose how these different impairments in self-reflection are linked with one another.     

Screening detoxifying inpatients with substance-related disorders for a major depressive disorder

The Beck Depression Inventory-Fast Screen for Medical Settings (BDI-FS; [Beck, Steer, & Brown, 2000]) and the Mood Module (MM) from the Primary Care Evaluation of Mental Disorders [Spitzer, Williams, Kroenke, Linzer, deGruy, III, Hahn, & Brody, 1995] were used to screen 100 inpatients detoxifying from alcohol, illicit substances, or both for a major depressive disorder (MDD). Receiver operating characteristic (ROC) analyses indicated that both tests were highly and comparably effective in differentiating patients who were and not diagnosed with a MDD; the ROC areas-under-curves for the BDI-FS and MM were, respectively, .87 and .84. A BDI-FS cut-off score of 10 and above had 90% sensitivity and 78% specificity rates, and a MM cut-off score of 7 and above had 90% sensitivity and 72% specificity rates for discriminating patients with and without a MDD. The clinical advantages and disadvantages of both instruments for rapidly screening detoxifying inpatients for clinical depression were discussed.     

Externalizing psychopathology in adulthood: a dimensional-spectrum conceptualization and its implications for DSM-V

Mental disorders involving antisocial behavior and substance use are genetically linked and vary continuously. The authors present a review and integrative conceptualization of these observations in terms of a dimensional and hierarchically organized externalizing spectrum. As a foundation for this conceptualization, the authors introduce a quantitative, model-based approach to comparing categorical and continuous conceptions of psychopathology and apply this approach in an empirical study of patterns of comorbidity among externalizing disorders as defined in the Diagnostic and Statistical Manual of Mental Disorders. The authors present evidence that comorbidity among externalizing disorders is best modeled by an underlying normally distributed continuum of risk for multiple disorders within the externalizing spectrum. The authors conclude by discussing implications of the externalizing spectrum conceptualization for classification of disorders in the upcoming 5th edition of the Diagnostic and Statistical Manual of Mental Disorders.     

Diathesis-stress theories in the context of life stress research: implications for the depressive disorders.

Advances in the conceptualization and measurement of life stress in the past 2 decades raise several questions concerning traditional diathesis-stress theories of psychopathology. First, comprehensive measures of life stress force investigators to become more precise about the particular stressful circumstances hypothesized to interact with diatheses. Second, the influence of the diathesis on a person's life is typically ignored, which results in several types of possible bias in the assessment of life stress. Finally, information is available on diatheses and stress for specific disorders to provide a foundation for more empirically based hypotheses about diathesis-stress interactions. This possibility is outlined for depression. Such an approach provides the basis for developing broader, yet more specific, frameworks for investigating diathesis-stress theories of psychopathology in general and of depression in particular.     

Primary prevention of secondary disorders: A proposal and agenda

This paper calls for consideration of a new class of preventive interventions designed explicitly to prevent comorbidity of psychiatric disorders. Epidemiologic data show that successful interventions of this type could be extremely valuable, as up to half of lifetime psychiatric disorders and an even larger percent of chronic and seriously impairing disorders occur to people with a prior history of some other disorder. Furthermore, a review of etiologic hypotheses concerning the causes of comorbidity suggests that interventions aimed at primary prevention of secondary disorders might be feasible. However, more basic risk factor research is needed on the causes of comorbidity before we can make a clear assessment of feasibility and discover promising intervention targets. A number of methodological problems arise in carrying out this type of formative research. These problems are reviewed and suggestions are offered for solutions involving innovations in measurement, design, and data analysis.     

Implications of research for the treatment of depressive disorders during childhood

Basic research into the prevalence, natural course, and phenomena of comorbidity of depressive disorders during childhood are reviewed and implications of this research for treating depressed youths are noted. Results of investigations into the biological aspects of depression are integrated into a multifactorial model of depressive disorders during childhood and the efficacy of pharmacological interventions is discussed. Cognitive theory is integrated with attachment theory to explain a possible avenue to the development of depressive disorders during childhood. Interpersonal therapy has emerged as a potentially effective intervention for depressed youths. Basic tenets of this treatment model are compared and contrasted to a cognitive-behavioral treatment model, and a hybrid treatment referred to as “cognitive therapy within the interpersonal context” is proposed.     

The effect of Axis II disorders on the outcome of treatment of anxiety and unipolar depressive disorders: a review

Psychiatric and other clinicians have often speculated on whether the presence of a personality disorder would indicate a poorer course of treatment for an Axis I disorder. Starting around 1990, the standardized criteria of the DSM increased interest in examining this area empirically. This report updates my previous reviews and examines other writing in this area. There is still a considerable body of evidence indicating that personality may cause a poorer treatment outcome of an Axis I disorder; however, there are also intriguing new developments. The introduction of new drug treatments that may be helpful with some dysfunctional personality traits changes some of the findings and may suggest that there may be preferential treatments for some Axis I patients with certain comorbid personality traits. (In certain cases this may apply to some specific psychotherapy techniques as well.) In addition, at times, personality traits may predict a positive outcome to treatment. This review is an attempt to bring together this diverse area and suggest where fruitful areas of research and intervention may possibly be found.     

Personality disorder research agenda for the DSM-V

The American Psychiatric Association is sponsoring a series of international conferences to set a research agenda for the development of the next edition of the diagnostic manual. The first conference in this series, "Dimensional Models of Personality Disorder: Etiology, Pathology, Phenomenology, and Treatment," was devoted to reviewing the existing research and setting a future research agenda that would be most effective in leading the field toward a dimensional classification of personality disorder. The purpose of this article, authored by the Steering Committee of this conference, was to provide a summary of the conference papers and their recommendations for research. Covered herein are the reviews and recommendations concerning alternative dimensional models of personality disorder, behavioral genetics and gene mapping, neurobiological mechanisms, childhood antecedents, cross-cultural issues, Axes I and II continuity, coverage and cutoff points for diagnosis, and clinical utility.     

The role of rumination in depressive disorders and mixed anxiety/depressive symptoms

Several studies have shown that people who engage in ruminative responses to depressive symptoms have higher levels of depressive symptoms over time, after accounting for baseline levels of depressive symptoms. The analyses reported here showed that rumination also predicted depressive disorders, including new onsets of depressive episodes. Rumination predicted chronicity of depressive disorders before accounting for the effects of baseline depressive symptoms but not after accounting for the effects of baseline depressive symptoms. Rumination also predicted anxiety symptoms and may be particularly characteristic of people with mixed anxiety/depressive symptoms.