Depressive personality disorder: rates of comorbidity with personality disorders and relations to the five-factor model of personality

Depressive personality disorder (DPD) is listed in the DSM-IV as one of the "Disorders for Further Study." In this investigation we examined (1) the rates of comorbidity of DPD with the 10 personality disorders (PDs) in the main text of DSM-IV, and (2) the convergent and discriminant validity of DPD in its relation to the 30 facet traits of the Five-Factor Model of personality (FFM). One hundred and sixty-nine participants with psychiatric diagnoses were interviewed with the Structured Clinical Interview for DSM-IV Personality Disorders Questionnaire (SCID-II) and completed the Revised NEO Personality Inventory (NEO PI-R). A total of 26 (15%) of the participants met diagnostic criteria for at least one of the 10 main text PDs, and 15 (9%) met criteria for DPD. Of those who met criteria for DPD, 10 (59%) of the participants also met criteria for one or more of the 10 main text PDs. Regression analyses indicated a four-facet trait set derived from the NEO PI-R thought to be uniquely associated with DPD accounted for a significant amount of variance in DPD SCID-II PD scores and was significantly larger for DPD than it was for the 9 of the 10 main text PDs; the sole exception was for avoidant PD. Diagnostically, DPD overlaps significantly with other PDs but is distinguishable in its unique relation with traits from the FFM.     

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.     

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.     

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.     

Borderline personality disorder from the perspective of general personality functioning

The authors extended previous work on the hypothesis that borderline personality disorder (BPD) can be understood as a maladaptive variant of personality traits included within the 5-factor model (FFM) of personality. In each of 3 samples, an empirically derived prototypic FFM borderline profile was correlated with individuals' FFM profiles to yield a similarity score, an FFM borderline index. Results across all samples indicated that the FFM borderline index correlated as highly with existing borderline measures as they correlated with one another, and the FFM borderline index correlated as highly with measures of dysfunction, history of childhood abuse, and parental psychopathology as did traditional measures of BPD. Findings support the hypothesis that BPD is a maladaptive variant of FFM personality traits.     

Dimensional personality traits and the prediction of DSM-IV personality disorder symptom counts in a nonclinical sample

The third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; APA, 1980) set forth a categorical system of personality psychopathology that is composed of discrete personality disorders (PDs), each with a distinct set of diagnostic criteria. Although this system is widely accepted and highly influential, alternative dimensional approaches to capturing personality psychopathology have been proposed. Three dimensional models of personality have garnered particular attention-the Five-Factor Model (FFM; Costa & McCrae, 1992), the Seven-Factor Psychobiological Model of Temperament and Character (Seven-Factor Model; Cloninger, Svrakic, & Przybeck, 1993); and the 18-factor model of personality pathology (18-factor model; Livesley, 1986). Although the personality traits from each of these models has been examined in relation to the ten personality disorders in the DSM-IV, no study has examined the comparative and incremental validity of these models in predicting PD symptoms for these ten disorders. Using self-report instruments that measure these models and the ten DSM-IV PDs, correlation and linear regression analyses indicate that traits from all three models had statistically significant associations with PD symptom counts. Hierarchical regressions revealed that the 18-factor model had incremental predictive validity over the FFM and Seven-Fac-tor Model in predicting symptom counts for all ten DSM-IV PDs. The FFM had incremental predictive validity over the Seven-Factor Model model for all ten disorders and the Seven-Factor was able to add incremental predictive validity over the 18-factor model for five of the ten PDs and for eight of the ten disorders relative to the FFM.     

The dimensionality of dependent personality disorder

The criteria for dependent personality disorder (DPD) in DSM-IV appear to fall into two categories: dependent and attachment behaviors. The relevance of this division was evaluated in a sample of 182 patients admitted to a national Norwegian psychiatric hospital. Principal Components Analysis of all items belonging to the most frequent personality diagnoses revealed six components. The items for DPD formed two components, labeled attachment/abandonment and dependency/incompetence. Two criteria for borderline personality disorder also loaded on the attachment/abandonment component, while six criteria for avoidant personality disorder loaded on the dependency/incompetence component. Early Maladaptive Schemas of abandonment and failure correlated significantly higher with the attachment/abandonment component than with the dependency/incompetence component.     

A comparative study of the dimensions and facets of the five-factor model in the diagnosis of cases of personality disorder

Two national samples of psychologists (n = 92, n = 89) rated personality disorder cases using either the five factors (domains) or the 30 facets of the five-factor model (FFM) to examine reliability and clinical utility of the model when used as a diagnostic tool. The cases were prototypic and nonprototypic cases representing the three clusters of personality disorders in the DSM-IV. Although confidence was higher using the factors rather than the facets to rate the cases, interrater reliability was similar and the facets were rated more useful for professional communication, case conceptualization, and treatment. Mean ratings for the prototypic cases supported the theorized relationships between those personality disorders and the FFM. Principal components factor analysis of the facet ratings largely replicated the structure of the FFM with only a few facets failing to load with their superordinate dimension in the model. Implications for use of the FFM with personality disorder are discussed.     

A five-factor measure of dependent personality traits

This study provides convergent, discriminant, and incremental validity data for a new measure of dependent personality traits from the perspective of the five-factor model (FFM). Dependent personality trait scales were constructed as maladaptive variants of FFM facets (e.g., Gullibility as a maladaptive variant of FFM trust). Based on responses from 383 undergraduates, the convergent validity of the Five-Factor Dependency Inventory (FFDI) scales was tested with respect to 2 measures of the FFM, 6 dependency trait scales, and 4 measures of dependent personality disorder. Discriminant validity was tested with respect to FFM facets from alternative domains. Incremental validity was tested with respect to the ability of the FFM dependent personality trait scales to account for variance in 2 established measures of dependency, after variance accounted for by respective FFM facet scales and other measures of DPD was first removed. The results of this study provided support for the validity of the FFDI assessment of dependency from the perspective of the FFM.     

Convergent and discriminant validity of three measures of depressive personality disorder

Sixty-eight outpatients from a veterans' administration psychiatry clinic and community mental health center were assessed with 3 measures of depressive personality disorder (DPD)-the Diagnostic Interview for Depressive Personality Disorder (Gunderson, Phillips, Triebwasser, & Hirschfeld, 1994), the Depressive Personality Disorder Inventory (Huprich, Margrett, Barthelemy, & Fine, 1996), and the Structured Clinical Interview for DSM-IV Axis II Disorders (First, Gibbon, Spitzer, Williams, & Benjamin, 1997a)-to evaluate their convergent and discriminant validity. Evidence supporting the measures' validity was mixed. The rate of convergence of depressive personality diagnoses across 3 measures was less than optimal, but the degree of intercorrelation among the measures was strong. Although depressive personality scores had moderate levels of intercorrelations with other personality disorders, the degree of intercorrelation decreased substantially after controlling for depressive symptoms. I conclude that further work is needed to strengthen the validity of measures of DPD.     

Differentiating avoidant and depressive personality disorders

The purpose of this study was to test a priori predictions about the way in which avoidant personality disorder (APD) can be differentiated from depressive personality disorder (DPD) in a clinical population. Psychiatric outpatients were administered two measures of DPD, including the SCID-II for other DSM-IV Axis II personality disorders, along with criterion measures upon which the two disorders would be differentiated. APD was found to be most strongly associated with state and trait measures of anxiety, while DPD was most strongly associated with state and trait measures of hostility. Individuals with DPD had higher mean scores on measures of hostility than those without DPD, and individuals with APD had higher mean scores on measures of anxiety than those without APD. However, DPD measures were also significantly correlated with state and trait measures of anxiety and APD with measures of depressive symptoms. Furthermore, anxiety was found to be higher in some groups of individuals with DPD than those with APD. It is concluded that the level of hostility in this DPD population appears to be an important symptom by which to differentiate the two disorders and that a reconsideration of including DPD criterion #4 -- prone to brooding and worrying -- may be justified. Furthermore, the SCID-II interview may be better at differentiating DPD and APD than a self-report measure of DPD.     

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.     

The construct validity of depressive personality disorder

This study examined the construct validity of depressive personality disorder (DPD: American Psychiatric Association, 1994). Adult psychiatric outpatients (N = 900) underwent comprehensive Axis I and II evaluations and provided data on 4,768 of their 1st-degree relatives. Despite modest overlap, DPD was not redundant with any Axis I or II disorder. Participants with DPD exhibited more Axis I and Axis II comorbidity, and greater psychosocial dysfunction, than participants without DPD. Relatives of participants with DPD had higher rates of mood disorders, alcohol abuse, and antisocial personality. Results are consistent with findings of several other similar investigations. The authors argue that DPD is a valid construct and should be conceptualized as a personality disorder as opposed to a mood disorder.     

Evaluation of the SCID-II personality disorder traits for DSM-IV: coherence, discrimination, relations with general personality traits, and functional impairment

The utility of the DSM personality disorder (PD) system remains a concern. The strategy employed represents one approach designed to evaluate and improve the diagnostic efficiency of the SCID-II PDs. Using a sample of 203 patients, SCID-II PD items-based on the criterion sets of the 10 DSM-IV PDs-were evaluated with respect to (a) convergent validity; (b) divergent validity; (c) relation to general personality traits; and (d) association with functional impairment. Only Borderline PD items were satisfactory on all four evaluation criteria. Histrionic and Obsessive-Compulsive PD items met criteria for convergent and divergent validity and relation to personality dimensions of the Five-Factor Model of Personality (FFM) but were not related to functional impairment, suggesting they might be reconsidered as disorders. Schizotypal PD items met three of the four criteria but showed no relation to FFM dimensions, suggesting that it may be a candidate for reassignment to Axis I.     

The depressive personality disorder inventory and current depressive symptoms: implications for the assessment of depressive personality

The Depressive Personality Disorder Inventory (DPDI; Huprich, Margrett, Barthelemy, & Fine, 1996; see Appendix) was created to assess Depressive Personality Disorder in clinical and nonclinical samples. Since its creation, the DPDI has been used in multiple studies, and the psychometric properties of the measure have generally supported its reliability, convergent validity, and construct validity; however, evidence for the measure's discriminant validity has been mixed. Specifically, the DPDI tends to correlate highly with measures of current depressive symptoms, which limits its efficacy in differentiating current depressive symptoms from a depressive personality structure. A principal components analysis of 362 individuals who completed both the DPDI and Beck Depression Inventory (BDI-II; Beck, Steer, & Brown, 1996) found that 49% of the variance was accounted for in two components. Seven items from the DPDI loaded more strongly on the first component composed of many BDI-II items. These items were removed in order to create a measure believed to assess DPD without the confounding influence of current depressive symptomology. Principal components analysis of the revised measure yielded three components, accounting for 46% of the variance. The revised DPDI was used to calculate convergent, discriminant, and construct validity coefficients from measures used in former studies. Virtually no improvement in the validity coefficients was observed. It is concluded that assessing DPD via self-report is limited in its utility.     

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.     

Scoring the DSM-IV personality disorders using the Five-Factor Model: development and validation of normative scores for North American, French, and Dutch-Flemish samples

Five-Factor Model (FFM) personality disorder (PD) counts have demonstrated significant convergent and discriminant validity with DSM-IV PD symptoms. However, these FFM PD counts are of limited clinical use without normative data because it is difficult to determine what a specific score means with regard to the relative level of elevation. The current study presents data from three large normative samples that can be used as norms for the FFM PD counts in the respective countries: United States (N = 1,000), France (N = 801), and Belgium-Netherlands (N = 549). The present study also examines the performance, with regard to diagnostic efficiency, of statistically-defined cut-offs at 1.5 standard deviations above the mean (T > or = 65) versus previously identified cut-offs using receiver-operator characteristics (ROC) analyses. These cut-offs are tested in three clinical samples-one from each of the aforementioned countries. In general, the T > or = 65 cut-offs performed similarly to those identified using ROC analyses and manifested properties relevant to a screening instrument. These normative data allow FFM data to be used in a flexible and comprehensive manner, which may include scoring this type of personality data in order to screen for DSM-IV PD constructs.