Passive-aggressive (negativistic) personality disorder: a population-based twin study

The objective of this study was to investigate the familial aggregation of passive aggressive personality disorder (PAPD), and explore issues regarding PAPD raised by the DSM-IV Personality Disorder Work Group. Two thousand seven hundred and ninety-four Norwegian twins from the population-based Norwegian Institute of Public Health Twin Panel were interviewed with the Structured Interview for DSM-IV Personality (SIDP-IV). Because of the rarity of the twins meeting full diagnostic criteria for PAPD a dimensional representation of the disorder was used for the analyses. Overlap with other axis II disorders was assessed by polychoric correlations, while familial aggregation was explored by structural equation twin models. Overlap was highest with paranoid (r = 0.52) and borderline personality disorder (r = 0.53), and lowest with schizoid (r = 0.26). Significant familial aggregation was found for PAPD. The twin correlations and parameter estimates in the full model indicated genetic and shared environmental effects for females, and only shared environmental effects for males, but the prevalence of endorsed PAPD criteria in this community sample was too low to permit us to conclude with confidence regarding the relative influence of genetic and shared environmental factors on the familial aggregation of PAPD.     

A comparison of passive-aggressive and negativistic personality disorders

Passive-aggressive personality disorder (PAPD) has historically played an important role in clinical theorizing and was diagnosable prior to the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994), in which the construct was relabeled negativistic (NEGPD), expanded to include negative affective symptoms, and appendicized. In this study we tested the hypothesis that the expansion of PAPD to include content related to negative moods and nonspecific personality pathology compromised its discriminant validity. In an undergraduate sample (N = 1,215), a self-report measure of PAPD was only moderately related to NEGPD and showed less diagnostic overlap with other personality disorders than NEGPD. Furthermore, a conjoint factor analysis yielded a strong first factor (moodiness) that appeared less specific to passive-aggressive behavior than 3 other factors (irresponsibility, inadequacy, and contempt). We conclude that future research on this potentially important clinical construct should focus on core passive-aggressive features and abandon the negativistic content that has been added to it in successive editions of the DSM.     

Rorschach aggression variables: a study of reliability and validity

This study investigated the extent to which 6 Rorschach variables of aggression (A1, A2, AG, MOR, AgC, AgPast) are related to one another, to the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) Cluster B personality disorder criteria, and to self-report measures of anger, aggression, and antisocial behavior. Seventy-eight patients were found to meet DSM-IV criteria for an Axis II disorder, Cluster A personality disorder (paranoid, schizoid, schizotypal) = 9, Cluster B (antisocial personality disorder [ANPD] = 16, borderline personality disorder [BPD] = 23, histrionic personality disorder = 5, narcissistic personality disorder = 12) = 56, and Cluster C personality disorder (avoidant, dependent, obsessive-compulsive) = 13. The results of this study indicated that (a) these 6 Rorschach aggression variables can be scored reliably; (b) 2 factors, revealed by factor analysis, accounted for 77% of the total variance; (c) selected variables were found to be empirically related to DSM-IV diagnostic criteria for ANPD and BPD; and (d) selected variables were found to be empirically related to a self-report measure of anger and antisocial practices. The conceptual nature and clinical utility of these Rorschach aggression variables as well as implications for future research are discussed.     

A Comparison of Passive–Aggressive and Negativistic Personality Disorders

Passive–aggressive personality disorder (PAPD) has historically played an important role in clinical theorizing and was diagnosable prior to the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM–IV]; American Psychiatric Association, 1994), in which the construct was relabeled negativistic (NEGPD), expanded to include negative affective symptoms, and appendicized. In this study we tested the hypothesis that the expansion of PAPD to include content related to negative moods and nonspecific personality pathology compromised its discriminant validity. In an undergraduate sample (N = 1,215), a self-report measure of PAPD was only moderately related to NEGPD and showed less diagnostic overlap with other personality disorders than NEGPD. Furthermore, a conjoint factor analysis yielded a strong first factor (moodiness) that appeared less specific to passive–aggressive behavior than 3 other factors (irresponsibility, inadequacy, and contempt). We conclude that future research on this potentially important clinical construct should focus on core passive–aggressive features and abandon the negativistic content that has been added to it in successive editions of the DSM.     

Use of the TAT in the Assessment of DSM-IV Cluster B Personality Disorders

The Social Cognition and Object Relations Scale (SCORS), developed by Westen, Lohr, Silk, Kerber, and Goodrich (1985), is a diagnostic instrument used to assess an array of psychological functioning by using clinical narratives such as the Thematic Apperception Test (TAT; Murray, 1943) stories. This study investigated the utility of the SCORS to differentiate between Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) antisocial personality disorder (ANPD), borderline personality disorder (BPD), narcissistic personality disorder (NPD), and Cluster C personality disorder (CPD). A sample of 58 patients was separated into four groups: ANPD (n = 9), BPD (n = 21; 18 with a primary BPD diagnosis and 3 with prominent borderline traits who met 4 of the 5 DSM-IV criteria necessary for a BPD diagnosis), NPD (n = 16; 8 with a primary NPD diagnosis and 8 with prominent narcissistic traits who met 4 of the 5 DSM-IV criteria necessary for a NPD diagnosis), and CPD (n = 12). These groups were then compared on the 8 SCORS variables by using 5 TAT cards (1, 2, 3BM, 4, and 13MF). Spearman-Brown correction for 2-way mixed effects model of reliability for the 8 SCORS variables ranged from .70 to .95. The results of categorical and dimensional analyses indicate that (a) the SCORS variables can be used to differentiate ANPD, BPD, and NPD; (b) the BPD group scored significantly lower (greater maladjustment) than did the CPD group on certain variables; (c) the BPD group scored significantly lower (greater maladjustment) than did the NPD group on all 8 SCORS variables; (d) the ANPD group scored significantly lower than did the NPD group on certain variables; (e) certain variables were found to be empirically related to the total number of DSM-IV ANPD, BPD, and NPD criteria; and (f) certain variables were found to be empirically related to Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) personality disorder scales. The results of this study are discussed in terms of clinical utility, conceptual, and theoretical implications.     

Use of the TAT in the assessment of DSM-IV cluster B personality disorders

The Social Cognition and Object Relations Scale (SCORS), developed by Western, Lohr, Silk, Kerber, and Goodrich (1985), is a diagnostic instrument used to assess an array of psychological functioning by using clinical narratives such as the Thematic Apperception Test (TAT; Murray, 1943) stories. This study investigated the utility of the SCORS to differentiate between Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) antisocial personality disorder (ANPD), borderline personality disorder (BPD), narcissistic personality disorder (NPD), and Cluster C personality disorder (CPD). A sample of 58 patients was separated into four groups: ANPD (n = 9), BPD (n = 21; 18 with a primary BPD diagnosis and 3 with prominent borderline traits who met 4 of the 5 DSM-IV criteria necessary for a BPD diagnosis), NPD (n = 16; 8 with a primary NPD diagnosis and 8 with prominent narcissistic traits who met 4 of the 5 DSM-IV criteria necessary for a NPD diagnosis), and CPD (n = 12). These groups were then compared on the 8 SCORS variables by using 5 TAT cards (1, 2, 3BM, 4, and 13MF). Spearman-Brown correction for 2-way mixed effects model of reliability for the 8 SCORS variables ranged from .70 to .95. The results of categorical and dimensional analyses indicate that (a) SCORS variables can be used to differentiate ANPD, BPD, and NPD; (b) the BPD group scored significantly lower (greater maladjustment) than did the CPD group on certain variables; (c) the BPD group scored significantly lower (greater maladjustment) than did the NPD group on all 8 SCORS variables; (d) the ANPD group scored significantly lower than did the NPD group on certain variables; (e) certain variables were found to be empirically related to the total number of DSM-IV ANPD, BPD, and NPD criteria; and (f) certain variables were found to be empirically related to Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) Personality disorder scales. The results of this study are discussed in terms of clinical utility, conceptual, and theoretical implications.     

Validation of the dimensional factor structure of the personality psychopathology five in clinical and nonclinical samples

Confirmatory factor analysis (CFA) was used to determine whether the latent structure underlying the items composing the MMPI-2 Personality Psychopathology Five scales (PSY-5; Harkness, McNulty, & Ben-Porath, 1995) is representative of the theoretical model that informed their construction. Results from the CFA revealed a good fit between the hypothesized five-factor model and the obtained latent factor structure in both clinical (n = 284) and nonclinical (n = 351) samples. Moreover, the PSY-5 model proved to be a better fit than a random five-factor model and a one-factor model. Correlations between the PSY-5 scales and a set of MMPI-2 (DSM-IV) personality disorder scales provided additional evidence of convergent and discriminant validity.     

The central domains of personality pathology in psychiatric patients

There is general agreement that the classification of personality disorders in DSM-IV is unsatisfactory. We systematically reviewed all studies that have analyzed patterns of personality disorder symptoms and signs in psychiatric patients; twenty-two papers were included in the final synthesis. There is reasonable consistency over the number and type of personality pathology traits reported despite differing samples, varying assessment methods, and different statistical manipulations. There are three or four high order traits; an externalizing factor incorporating borderline, narcissistic, histrionic, and antisocial traits (the latter is sometimes recorded as a separate trait); an internalizing factor incorporating avoidant and dependent traits; a schizoid factor; and often a compulsive factor. Using these domains of personality pathology would simplify classification, have higher clinical utility, and allow relatively easy translation of current research.     

Aesthetic preference and DSM-IIIR personality disorders

This report tested whether those individuals with a cluster B DSM-IIIR personality disorder (narcissistic, borderline, antisocial or histrionic) had higher scores for aesthetic preference for visually complex drawings using the Barron-Welch Art Scale. In a sample of 141 patients and controls, the 56 subjects who met the criteria for one of the cluster B personality disorder diagnoses displayed higher Barron-Welch Art Scale Scores. A multiple regression analysis showed that narcissistic and borderline personality disorder contributed positively, while dependent personality disorder, negatively to preference for complexity. The findings support the notion that aesthetic choices and values reflected through the dimension of openness to experience may contribute to the behavioral manifestations of the personality disorders.     

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.     

Transference Focused Psychotherapy for Patients with Comorbid Narcissistic and Borderline Personality Disorder

Clinical experience involving the treatment of patients with comorbid borderline and narcissistic personality disorders suggests that this patient population is among the more difficult to treat within the personality disorder spectrum. In this article, we present refinements of Transference Focused Psychotherapy (TFP) based on our clinical experience with and research data on patients with comorbid narcissistic personality disorder/borderline personality disorder (NPD/BPD). We briefly review object relations formulations of severe narcissistic pathology, as well as recent research in attachment and the allied concept of mentalization, which have provided a new lens through which to view narcissistic disorders. The research findings from two randomized clinical trials demonstrating the efficacy and effectiveness of TFP are presented. The data from the two Randomized Clinical Trials (RCT) allowed for the study of the characteristics of the subgroup of borderline personality disorder patients who have comorbid NPD/BPD. Findings on comorbidity, attachment status, capacity for mentalization, and level of personality organization of borderline patients with comorbid NPD/BPD, compared with borderline patients without comorbid narcissistic pathology (BPD), are presented. Clinical implications of the observed group differences are discussed, with a focus on refinements in the technique of TFP. Clinical case material is presented to illustrate the specific challenges posed by narcissistic patients to carrying out TFP in each phase of treatment.     

Narzisstische Persönlichkeitsstörung

Narcissism is a multifaceted term which encompasses traits of normal personality as well as a specific personality disorder. While much research has been concerned with narcissism as a trait there are only few empirical studies on narcissistic personality disorder (NPS). The current diagnostic system of NPS according to DSM-5 (section II) focuses on grandiose narcissism whereas vulnerable narcissism, which is emphasized by clinicians and researchers, has not yet been recognized. While treating NPD patients an increased suicide risk has to be taken into consideration. Psychotherapy of narcissistic patients mainly focuses on processes during patient-therapist interactions, the analysis and processing of grandiose and vulnerable schemas, emotion regulation techniques and a correction of narcissistic behavior in favor of prosocial interactions.     

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.     

Gender differences in a clinical sample of patients with borderline personality disorder

The aim of the study was to investigate gender differences and similarities in patients with borderline personality disorder (BPD) with respect to Axis I comorbidity, Axis II comorbidity, general psychopathology (Symptom Checklist 90-Revised), and dimensional personality traits (NEO-Personality-Inventory Revised [NEO-PI-R] and the Dimensional Assessment of Personality Profile Basic questionnaire [DAPP-BQ]). Fifty-seven men and 114 women with BPD were included in the study. Regarding Axis I and II disorders in an exploratory analysis, men with BPD more often fulfilled the diagnostic criteria for binge eating disorder, antisocial personality disorder, narcissistic personality disorder, and conduct disorder in childhood, whereas women had higher frequencies of bulimia nervosa, posttraumatic stress disorder, and panic disorder with agoraphobia. After correcting for multiple tests, only the gender differences in narcissistic and antisocial personality disorder remained significant. In the SCL-90-R profile, no significant gender differences could be identified. In the exploratory analysis of the dimensional personality traits, women showed higher rates on the NEO-PI-R main factors (Neuroticism and Agreeableness) compared to men. In the DAPP-BQ profile, men reached higher sores on the main factor, Dissocial Behavior. When correcting for multiple tests, gender differences still existed for Neuroticism and Dissocial Behavior. Our results argue for gender differences in Axis I and II comorbidity and dimensional personality traits in BPD. However, in general, more similarities than differences were shown in this study.     

The relationship between five-factor personality measurements and ICD-10 personality disorder dimensions: results from a sample of 229 subjects

This article examines the relationship between the five-factor model (FFM) and dimensional ICD-10 personality disorders. In a follow-up study of a child and adolescent psychiatric cohort, former patients and controls were assessed with NEO-FFI and the IPDE interview (CD-10 personality disorder). Full data were available for 229 subjects (149 former patients, 80 controls). Multiple regression analysis showed that the five factors of the FFM as independent variables explained between 5% (schizoid personality disorder) and 32% (anxious personality disorder) of the variance of ICD-10 dimensional personality disorder scores. For the two types of emotionally unstable personality disorder dimension (impulsive and borderline), for anxious (avoidant) personality disorder dimension and for the total score of any personality disorder dimension, FFM explained between 17% and 32% of the variance with almost identical results for the former patient group and the control group. High neuroticism was a feature of paranoid, emotionally unstable, histrionic, anankastic, anxious (avoidant), and dependent personality disorder dimensions, whereas low agreeableness was found in dissocial, emotionally unstable and histrionic personality disorder dimensions. Low extraversion was found in schizoid, anxious (avoidant) and dependent personality disorder dimensions, whereas histrionic PD dimension correlated with high extraversion. We find that the FFM is valuable for the further understanding not only of DSM-IV but also of ICD-10 personality disorder dimensions. The differences between ICD-10 and DSM-IV in this respect seem to be small.     

The joint structure of DSM-IV Axis I and Axis II disorders

The Diagnostic and Statistical Manual (4th ed. [DSM-IV]; American Psychiatric Association, 1994) distinction between clinical disorders on Axis I and personality disorders on Axis II has become increasingly controversial. Although substantial comorbidity between axes has been demonstrated, the structure of the liability factors underlying these two groups of disorders is poorly understood. The aim of this study was to determine the latent factor structure of a broad set of common Axis I disorders and all Axis II personality disorders and thereby to identify clusters of disorders and account for comorbidity within and between axes. Data were collected in Norway, through a population-based interview study (N = 2,794 young adult twins). Axis I and Axis II disorders were assessed with the Composite International Diagnostic Interview (CIDI) and the Structured Interview for DSM-IV Personality (SIDP-IV), respectively. Exploratory and confirmatory factor analyses were used to investigate the underlying structure of 25 disorders. A four-factor model fit the data well, suggesting a distinction between clinical and personality disorders as well as a distinction between broad groups of internalizing and externalizing disorders. The location of some disorders was not consistent with the DSM-IV classification; antisocial personality disorder belonged primarily to the Axis I externalizing spectrum, dysthymia appeared as a personality disorder, and borderline personality disorder appeared in an interspectral position. The findings have implications for a meta-structure for the DSM.     

The structure of axis II disorders in adolescents: a cluster- and factor-analytic investigation of DSM-IV categories and criteria

The aim of this study was to ascertain whether the structure of personality disorder (PD) symptoms in adolescents assessed using DSM-IV diagnoses and diagnostic criteria resembles the structure intended for the diagnosis of PDs in adults. A national sample of clinicians rated DSM-IV Axis II criteria on 294 adolescent patients in treatment for enduring maladaptive personality patterns. Cluster analysis replicating procedures used in an adult sample by Morey (1988) identified considerable similarity between adult and adolescent PDs, as did exploratory factor analysis of ratings of diagnostic criteria, which yielded ten empirically derived factors that resembled the ten DSM-IV PDs. Cluster analysis and confirmatory factor analysis with indicators of Axis II symptoms produced mixed results in replicating the DSM-IV hierarchical structure of PDs (Clusters A, B, and C), although hierarchical models generally fared better than models specifying only first-order factors or clusters. The structure of personality pathology as assessed by Axis II criteria in adolescents resembles that outlined in DSM-IV Axis II for adults, suggesting that PDs can be assessed in adolescents as in adults. Whether this is an optimal way of diagnosing personality pathology in adolescence, however, requires further investigation.     

Personality characteristics of ADHD adults assessed with the Millon Clinical Multiaxial Inventory-II: evidence of four distinct subtypes

This study compared the personality characteristics of 104 adults diagnosed with attention deficit hyperactivity disorder (ADHD). Personality features were assessed with the MCMI-II (Millon, 1987). Participants were divided into 4 groups based on the presence of persisting oppositional defiant disorder (ODD) or other comorbid diagnoses (ADHD only, ADHD-comorbid, ADHD-ODD, ADHD-ODD-comorbid). Significant differences between these groups were present for 9 of the 13 MCMI-II personality scales, resulting in 4 modal personality styles. ADHD-only adults evidenced mild histrionic traits, whereas the ADHD-comorbid group was more often avoidant and dependent in personality style. ADHD-ODD adults showed histrionic, narcissistic, aggressive-sadistic, and negativistic traits whereas the ADHD-ODD-comorbid group had a combination of avoidant, narcissistic, antisocial, aggressive-sadistic, negativistic, and self-defeating personality features. Implications for treatment are discussed.     

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.