Sex bias in the diagnosis of personality disorders: A different approach

There has been considerable controversy regarding a possible sex bias in the diagnosis of personality disorders (PDs). However, prior research has at times confused a bias within clinicians who fail to adhere to the diagnostic criteria with a bias within the diagnostic criteria. Rather than assess whether females are more likely than males to be diagnosed with a respective disorder, the current study assesses whether the thresholds for the diagnosis of female-typed PDs are lower than the thresholds for male-typed PDs. Subjects completed two self-report inventories for the DSM-III-R personality disorders, and three inventories that assessed 30 aspects of personality dysfunction organized with respect to social dysfunction, occupational dysfunction, and personal distress. There was no indication that the diagnostic thresholds for personality disorders that occur more often in females is lower than the thresholds for the personality disorders that occur more often in males. The implications of these findings for the issue of sex biased diagnoses are discussed.     

Effects of sex and sex roles on the perceived maladaptiveness of DSM-IV personality disorder symptoms

This study investigated the influence of sex on the perceived maladaptiveness of DSM-IV personality disorder criteria based on previous findings that inconsistency of symptoms with sex roles affects the perception of personality disorder symptoms. The effects of rater characteristics (i.e., sex, sex role) were also examined. A total of 161 undergraduates (65 men, 96 women) rated the diagnostic criteria according to how maladaptive they were for males (male condition), females (female condition), or without regard to sex (neutral condition that served as a baseline) using a 7-point scale. Participants' sex role was determined using the Bem Sex Role (1981a) Inventory. Dependent and depressive personality disorder criteria (trend for borderline) were rated more maladaptive for females than males, whereas obsessive-compulsive personality disorder criteria were rated more maladaptive for males than females. Participant sex and sex role had little or no significant effects on the ratings. Results are compared with those of previous research. Methodological issues and implications for the diagnosis of personality disorders are discussed.     

Gender bias in diagnostic criteria for personality disorders: an item response theory analysis

The authors examined gender bias in the diagnostic criteria for Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision; American Psychiatric Association, 2000) personality disorders. Participants (N=599) were selected from 2 large, nonclinical samples on the basis of information from self-report questionnaires and peer nominations that suggested the presence of personality pathology. All were interviewed with the Structured Interview for DSM-IV Personality (B. Pfohl, N. Blum, & M. Zimmerman, 1997). Using item response theory methods, the authors compared data from 315 men and 284 women, searching for evidence of differential item functioning in the diagnostic features of 10 personality disorder categories. Results indicated significant but moderate measurement bias pertaining to gender for 6 specific criteria. In other words, men and women with equivalent levels of pathology endorsed the items at different rates. For 1 paranoid personality disorder criterion and 3 antisocial criteria, men were more likely to endorse the biased items. For 2 schizoid personality disorder criteria, women were more likely to endorse the biased items.     

A psychometric analysis of five DSM-III categories

Preliminary studies of interdiagnostician agreement have shown that the DSM-III holds promise for improving diagnostic reliability. This study examined the characteristics of five DSM-III diagnostic categories (schizophrenia, mania and schizotypal, narcissistic and borderline personality disorders) with respect to three psychometric criteria. Examined were the specificity, syndrome association and internal consistency of the diagnostic criteria for these disorders. Results suggested that of the diagnostic categories examined, the criteria for schizophrenia performed best under empirical scrutiny, while criteria for borderline and narcissistic personality disorders were more problematic. Suggestions are made for subsequent investigations into the internal validity of DSM-III.     

Self-Report and Observer Ratings of Personality Functioning: A Study of the OPD System

Recent considerations around DSM–5 criteria of personality disorders (PDs) demand new concepts of assessing levels of personality functioning. Of special interest are multiperspective approaches accounting for clinicians’ as well as patients’ points of view. The study investigates observer-rated and self-assessed levels of personality functioning measured by the level of structural integration as defined by the Operationalized Psychodynamic Diagnosis System (OPD). Both perspectives were positively related. The combination of both measures was most efficient in discriminating among 3 diagnostic groups of varying degrees of personality dysfunction. Future studies should take into account expert ratings as well as self-report data.     

Gender role and personality disorders

Many researchers have hypothesized relationships between personality disorders and gender role (i.e., masculinity and femininity). However, research has not addressed if people who are masculine or feminine more often meet the criteria for personality disorders. The present study examined whether college students (N = 665, 60% women) higher in masculinity or femininity more often exhibited features of the 10 DSM-IV personality disorders. Feminine men exhibited more features of all the personality disorders except antisocial. Dependent traits were associated with higher femininity and lower masculinity. Antisocial traits were associated with masculinity. Both men and women who typically behaved consistent with their gender had more narcissistic and histrionic features, whereas participants who typically behaved unlike their gender had more features of the Cluster A personality disorders.     

Empirical clusters of DSM-III personality disorders in violent offenders

Violent male offenders in a maximum security hospital and special units in prisons (N = 164) were interviewed with the Structured Clinical Interview for DSM-III Axis II disorders (SCID-II). Cluster analysis of the personality disorder criteria sets identified six diagnostic patterns: (1) antisocial-narcissistic; (2) paranoid-antisocial; (3) borderline-antisocial-passive-aggressive; (4) borderline; (5) compulsive-borderline; and (6) schizoid. Offenders in the first three groups had more extensive criminal careers, and most were identified as psychopaths by the Psychopathy Checklist-Revised (PCL-R). These Groups also had more frequent lifetime histories of substance abuse. A history of affective and anxiety disorders was more common in Groups 3 and 5, and almost two thirds of Group 2 had a history of psychotic disorder. The results emphasize that dangerous offenders are heterogeneous in personality pathology. They also suggest that personality disorder among violent offenders is more commonly represented by recurring patterns of covarying traits than by single categorical entities proposed in the DSM classification.     

Accurate diagnosis of personality disorders: Some critical factors

Issues pertaining to the accurate diagnosis of personality disorders are discussed from a scientist-practitioner perspective. An attempt is made to distinguish state (Axis I) from trait (Axis II) disorders, and personality (“normal”) from personality disorders (“abnormal”). The reliability and validity of personality disorder diagnoses are explored, and the four criteria for all personality disorder diagnoses are clarified: These criteria are: 1) presence of psychological symptomology, 2) stability over time, 3) consistency across situations, and 4) under-responsiveness to currently available treatments. Also, a distinction is made between categorical and dimensional diagnostic criteria, similar to the distinction between personality type and trait approaches. Recommendations are provided for improving the clinical and empirical work in this area, and implications for treatment are discussed.     

Differential impairment as an indicator of sex bias in DSM-IV criteria for four personality disorders

The aim of the present study was to investigate the possibility of sex bias in the diagnostic criteria for borderline, schizotypal, avoidant, and obsessive-compulsive personality disorders. A clinical sample of 668 individuals was evaluated for personality disorder criteria using a semistructured interview, and areas of functional impairment were assessed with both self-report and semistructured interview. The authors used a regression model of bias to identify bias as differences in slopes or intercepts between men and women in the relationship between each diagnostic criterion and level of impairment. The results suggest that most of the diagnostic criteria examined do not seem to display sex bias. However, those criteria that displayed evidence of bias came largely from the borderline diagnosis.     

The role of gender in the clinical presentation of patients with borderline personality disorder

This study examined gender differences in the pattern of comorbid disorders and degree of impairment among outpatients with borderline personality disorder (BPD). A total of 130 outpatients with BPD were assessed for various lifetime impulse-related disorders and post-traumatic stress disorder and for indices of impairment. Compared with women with BPD, men with BPD reported significantly more lifetime substance abuse disorders, antisocial personality and met criteria of intermittent explosive disorder that did not overlap with a diagnosis of BPD. Women with BPD reported significantly more lifetime eating disorders than men with BPD. No gender differences were found in degree of overall impairment. These results suggest that male and female patients with BPD, although equally distressed, present with different lifetime patterns of impulse-related disorders.     

Prevalence of Personality Disorders at Midlife in a Community Sample: Disorders and Symptoms Reflected in Interview,Self, and Informant Reports

This report is concerned with the prevalence of symptoms of specific personality disorders in a representative community sample and draws attention to the importance of different sources of diagnostic information. We recruited a sample of 1,630 people between the ages of 55 and 64 to participate in a study regarding personality and health. Using careful recruitment methods, our participation rate was 43 %. Participants completed the SIDP-IV interview as well as a questionnaire (self-report MAPP). Informants completed the same questionnaire (informant MAPP), describing the participant’s maladaptive personality characteristics. According to the diagnostic interview, 7 % of participants met criteria for exactly one PD, 1 % met criteria for 2 or 3 PDs, and 2 % met criteria for PD NOS (defined as 10 or more miscellaneous criteria). Avoidant and obsessive compulsive PDs were the most common types. Correlations between the three sources of information indicated significant agreement among these measurement methods, but they are not redundant. In comparison to interview and self-report data, informants reported more symptoms of personality pathology (except for avoidant PD). Symptoms of personality pathology are continuously distributed, and subthreshold features may have an important impact on health and social adjustment. In this community sample, rates of co-morbidity among PDs and the proportion of PDNOS diagnoses are substantially lower than reported from clinical samples. Future research must evaluate the validity of diagnostic thresholds and competing sources of diagnostic information in relation to important life outcomes.     

Prevalence of personality disorders among bulimics,nonbulimic binge eaters,and normal controls

We examined the comorbidity of bulimia and personality pathology among college women. Subjects included women (n=23) meeting DSM-III-R criteria for bulimia nervosa (bulimics), women (n=23) who reported binge eating but did not fulfill the criteria for bulimia nervosa (binge eaters), and women (n=23) who did not binge eat (normals). The subjects completed an assessment battery consisting of the Personality Disorders Examination and the SCID as well as the Beck Depression Inventory, the Rosenberg Self-Esteem Index, and measures of impulsivity and self-defeating tendencies. Fourteen of 23 bulimics (61%) met criterion for a personality disorder using DSM-III-R Axis II criteria. In comparison, 3 of 23 (13%) binge eaters and 1 of 23 (4%) normal subjects received an Axis II diagnosis. Borderline and self-defeating diagnoses were the predominant personality disorders in 96% of the bulimics exhibiting clinically significant personality pathology. Bulimics also exhibited significantly more depression, impulsivity, and self-defeating behavior and lower self-esteem than binge eaters and normals. The findings are discussed within a conceptual framework that posits an interaction between personality pathology and restrained eating.     

Aktuelle Entwicklungslinien in der Pers?nlichkeitsforschung im Jugendalter

Personality disorders in juveniles are still a controversially discussed topic. The aim of this paper is to describe the recent trend in personality research in adolescence and to outline perspectives in research and assessment. Recent study results have pointed out that personality disorders in juveniles can be reliably assessed with diagnostic instruments that have been developed for adults. At the same time there is a lack of specific instruments that can represent the characteristics during adolescence and that can differentiate personality disorders from youth crises. As some personality disorder dimensions also describe unstable developmental criteria we will focus separately on this differential diagnosis and meaning of stable versus transient personality characteristics in youth. The prevalence of personality disorders seems to be higher in adolescence than in adulthood. The stability, however, is comparable in adolescence and adulthood. Psychopathy as a subtype of the antisocial personality disorder ?C that can also be assessed in juveniles ?C will be discussed regarding its core and behavioral dimensions as well as primary and secondary subtypes. Furthermore, we discuss forensic issues when assessing personality disorders with respect to criminal responsibility. Overall we can show that more diagnostic longitudinal studies are essential in order to clarify under which conditions personality disorders develop, which factors influence its course and which interventions can change them.     

Gender differences in alcohol dependence: personality variables, psychopathological profile and personality disorders

In this paper, gender differences in personality, psychopathology and personality disorders of alcohol-dependent patients are described. The sample consisted of 158 alcohol-dependent patients attending a psychiatric outpatient clinic (105 men and 55 women). All participants were assessed with various assessment tools related to personality (Impulsiveness Scale, Sensation Seeking Scale and STAI), psychopathology (SCL-90-R, BDI and Inadaptation Scale) and personality disorders (IPDE). There were no differences in personality variables, but the women had more anxiety and depressive symptoms and also more problems to adapt to everyday life than did the men. Personality disorders were not as prevalent as in the case of men, and the most frequent among women were obsessive-compulsive, dependent and histrionic personality disorders. Implications of this study for further research are commented on.     

Capturing the psychopathic female: a prototypicality analysis of the comprehensive assessment of psychopathic personality (CAPP) across gender

Psychopathy in women has been subject to little systematic investigation; no coherent conceptualization of the disorder in women exists. Previous research is constrained by the reliance both on a male conceptualization of psychopathy and on assessment instruments developed, and primarily validated, with men. This study utilized a newly developed, broad, personality-based, and gender-sensitive lexical model of psychopathy, the Comprehensive Assessment of Psychopathic Personality (CAPP). Prototypical analysis was used to explore gender differences in the construct and the content validity of the CAPP model across gender. Symptoms were rated by international mental health professionals (N = 132). The findings support the content validity of the CAPP across gender and suggest that – at symptom and domain levels – psychopathic men and women have key similarities, but also that important gender differences exists. This has implications for the assessment of psychopathy in women, and has relevance for the proposed revision of diagnostic criteria for personality disorders. Copyright © 2011 John Wiley & Sons, Ltd.     

Impact of personality disorders on treatment outcome for female assault survivors with chronic posttraumatic stress disorder

This study examined the impact of comorbid personality disorders on the outcome of cognitive behavioral treatment for women with chronic posttraumatic stress disorder (PTSD). Seventy-five adult women with PTSD resulting from rape or nonsexual assault in adulthood or sexual abuse in childhood were treated with prolonged exposure with or without cognitive restructuring. Assessment of personality disorders found that 39% of participants met DSM-IV criteria for some personality disorder diagnosis. No difference was found between women with and without personality disorders on the prevalence of PTSD at the end of treatment. Participants with a personality disorder were less likely to attain good end-state functioning, but this may be attributable to the fact that they started off slightly worse than those without personality disorders. Finally, the comorbid patients treated by community therapists fared as well or better than those treated by cognitive behavioral treatment experts in posttreatment prevalence of PTSD and end-state functioning.     

Charting the future of axis II

Although there is general agreement that personality disorders are best conceptualized dimensionally, reflecting continuity with normal personality types, personality disorder traits, and personality disorders themselves, categorical systems continue to be utilized for clinical diagnostic purposes. The arguments for and against each approach are reviewed, and a proposal is presented for DSM-V that involves elements of both.     

Differentiation of Axis I and Axis II disorders

The revised 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1987) distinguishes between Axis I and Axis II disorders: Axis II includes personality (and developmental) disorders, and all others are on Axis I. This distinction is often useful, but the reification of Axis I and II constructs through diagnostic criteria sets that demarcate categorically distinct entities is at times problematic. We review the issues of differentiating personality from Axis I disorders, specifically illustrated by schizotypal and schizophrenic disorders, borderline and mood disorders, antisocial and substance use disorders, and avoidant personality from social phobia. The options for addressing their differentiation include adding exclusion criteria, shifting the placement of disorders, deleting overlapping criteria, adding differentiating criteria, and converting to a dimensional format.     

Personality assessment in DSM-5: empirical support for rating severity, style, and traits

Despite a general consensus that dimensional models are superior to the categorical representations of personality disorders in DSM-IV, proposals for how to depict personality pathology dimensions vary substantially. One important question involves how to separate clinical severity from the style of expression through which personality pathology manifests. This study empirically distinguished stylistic elements of personality pathology symptoms from the overall severity of personality disorder in a large, longitudinally assessed clinical sample (N = 605). Data suggest that generalized severity is the most important single predictor of current and prospective dysfunction, but that stylistic elements also indicate specific areas of difficulty. Normative personality traits tend to relate to the general propensity for personality pathology, but not stylistic elements of personality disorders. Overall, findings support a three-stage diagnostic strategy involving a global rating of personality disorder severity, ratings of parsimonious and discriminant valid stylistic elements of personality disorder, and ratings of normative personality traits.