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 self-report personality disorder inventories

There has been considerable controversy and research regarding gender biases in the diagnosis of personality disorders, but few studies have explored whether personality disorder self-report inventories might contain gender biases. The current study investigated whether items from three commonly used inventories evidence a potential for gender bias. Subjects were from outpatient mental health clinics. Items were considered gender biased if they exhibited gender differences and failed to correlate with or, more importantly, correlated negatively with dysfunction. Thirty-eight items evidenced potential bias, the majority of which were from Narcissistic scales. The implications of the results for the clinical assessment of purportedly maladaptive personality traits and for the construction of personality disorder scales are discussed.     

Are personality disorder criteria ethnically biased? A card-sort analysis

On the basis of methodology used in previous research on sex criterion bias, this study examined ethnicity criterion bias of personality disorders (PDs) defined in the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., Rev.) and included examination of sex as well as ethnicity. A card-sort analysis using undergraduate college students as sorters indicated that criteria for all of the PDs were applied disproportionately by ethnicity, resulting in particular ethnic groups receiving diagnoses for specific PDs. Criteria were sorted systematically such that diagnoses of antisocial and paranoid PDs were assigned to African Americans, schizoid PD was assigned to Asian Americans, and schizotypal PD was assigned to Native Americans. All other PDs were assigned to European Americans, whereas none of the criteria were sorted resulting in any PD diagnosis being applied to Latinos. Implications for clinicians, methodological considerations, and recommendations for future research are discussed.     

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.     

Sex and gender bias in self-report personality disorder inventories: item analysis of the MCMI-II, MMPI, and PDQ-R

There has been considerable controversy and research regarding sex bias in the diagnosis of personality disorders, but little has involved self-report inventories. Thus this study investigated items from the Millon Clinical Multiaxial Inventory-II (Millon, 1987), the Minnesota Multiphasic Personality Inventory (Morey, Waugh, & Blashfield, 1985), and the Personality Diagnostic Questionnaire-Revised (Hyler & Rieder, 1987). Subjects (N = 189) completed the Histrionic, Dependent, Antisocial, and Narcissistic scales from these inventories, along with the Bem Sex Role Inventory (Bem, 1974) and the Symptom Checklist-90-Revised (Derogatis, 1977). Items were considered to evidence sex or gender bias if they (a) failed to correlate with dysfunction and (b) exhibited sex or gender role differences. At least 13 items evidenced sex bias (76 items using a more liberal threshold). The majority were from Narcissistic scales; few Histrionic items evidenced sex or gender bias. Implications with respect to sex-bias assessment and item construction are discussed.     

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.     

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 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.     

Using a general model of personality to understand sex differences in the personality disorders

In the present study, a general model of personality was used to evaluate sex bias in the personality disorders (PD). This present study compared observed sex differences among the personality disorders (PD) with differences expected based on the Five Factor Model of personality functioning (FFM). Observed sex differences were obtained by metaanalyzing over 30 reports. Expected sex differences were computed using what is known about sex differences in the FFM traits and how these traits relate to the PDs. Agreement between observed and expected sex differences was quite good for eight of ten PDs. For histrionic PD, the obtained sex difference was larger than expected; for schizotypal personality disorder, an expected sex difference was not obtained. Implications of understanding sex differences in terms of the FFM are discussed and suggestions for future research are provided.     

Challenges associated with a polythetic diagnostic system: criteria combinations in the personality disorders

Converging research on the diagnostic criteria for personality disorders (PDs) reveals that most criteria have different psychometric properties. This finding is inconsistent with the PD diagnostic system according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994), which weights each criterion equally. The purpose of the current study was to examine the potential effects of using equal weights for differentially functioning criteria. Data from over 2,100 outpatients were used to analyze and score response patterns to the diagnostic criteria for 9 PDs within an item response theory framework. Results indicated that combinations that included the same number of endorsed criteria yielded differing estimates of PD traits, depending on which criteria were met. Moreover, trait estimates from subthreshold criteria combinations often overlapped with diagnostic (at-threshold or higher) combinations, indicating that there were subthreshold combinations of criteria that indicated as much or more PD than did some combinations at the diagnostic threshold. These results suggest that counting the number of criteria an individual meets provides only a coarse estimation of his or her PD trait level. Implications for the assessment of polythetically defined mental disorders and for the PD proposal for the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders are discussed.     

A simplified technique for scoring DSM-IV personality disorders with the Five-Factor Model

The current study compares the use of two alternative methodologies for using the Five-Factor Model (FFM) to assess personality disorders (PDs). Across two clinical samples, a technique using the simple sum of selected FFM facets is compared with a previously used prototype matching technique. The results demonstrate that the more easily calculated counts perform as well as the similarity scores that are generated by the prototype matching technique. Optimal diagnostic thresholds for the FFM PD counts are computed for identifying patients who meet diagnostic criteria for a specific PD. These threshold scores demonstrate good sensitivity in receiver operating characteristics analyses, suggesting their usefulness for screening purposes. Given the ease of this scoring procedure, the FFM count technique has obvious clinical utility.     

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.     

Sex differences in fetal habituation

There is some evidence for sex differences in habituation in the human fetus, but it is unknown whether this is due to differences in central processing (habituation) or in more peripheral processes, sensory or motor, involved in the response. This study examined whether the sex of the fetus influenced auditory habituation at 33 weeks of gestation, and whether this was due to differences in habituation or in the sensory or motor components using a set of four experiments. The first experiment found that female fetuses required significantly fewer stimulus presentations to habituate than males. The second experiment revealed no difference in the spontaneous motor behaviour of male and female fetuses. The third experiment examined auditory intensity thresholds for the stimuli used to habituate the fetus. No differences in thresholds were found between males and females, although there was inter-individual variability in thresholds. A final experiment, using stimuli individualized for that particular fetus' auditory intensity threshold, found that female fetuses habituated faster than males. In combination, the studies reveal that habituation in the human fetus is affected by sex and this is due to a difference in central 'information processing' of the stimuli rather than peripheral aspects of the response. It is argued that male and female fetuses present different neurobehavioural developmental trajectories, with females more advanced at 33 weeks than males. This study suggests that research examining prenatal behaviour should consider the factor of fetal sex. This may be particularly pertinent where there is an intention to use the results diagnostically.     

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.     

Cross-system concordance of personality disorder diagnoses of DSM-IV and diagnostic criteria for research of ICD-10

The aim in this study was to examine the cross-system concordance between the personality disorders (PDs) of DSM-IV and Diagnostic Criteria for Research of ICD-10 Classification of Mental and Behavioral Disorders, 10th rev. (ICD-10) PD diagnoses were made by a structured interview in a clinical psychiatric sample of 138 individuals. Both categorical and dimensional scores for each PD were established. The frequency of patients with a PD diagnosis on either classification who were also positive on the other varied from 26% for the schizoid PDs to 88% for the histrionic PDs. The chance-corrected agreement (Cohen's kappa) ranged from .37 to .94. The dimensional correlation (Pearson's r) between pairs of PD criteria sets was in the range of .79 to .98. In conclusion, when analyzed categorically, some of the PDs of DSM-IV and ICD-10-DCR were only moderately concordant. The reasons appear to be different criteria formulations and arbitrary thresholds for diagnoses. In contrast to categorical diagnoses, dimensional agreement was high, implicating similar trait-concept definitions. The least concordant pair of PD was antisocial (DSM-IV)-dissocial (ICD-10).     

Behandlungsleitlinie Persönlichkeitsstörungen

The S2 guidelines for the treatment of personality disorders (PD) are summarized. In the diagnostic assessment of personality disorders a clinical interview should be supplemented by (semi-) structured clinical interviews and self-report measures for the categorical and dimensional assessment of PDs. The results of the assessment process should be communicated to the patient based on a psycho-educational framework. The diagnosis should always be linked to the patient’s individual history. Psychotherapy is the treatment of choice for personality disorders. A detailed analysis of the patient’s problems as well as the definition of a hierarchy of treatment goals are part of the process of treatment planning. For three PDs empirical evidence for treatment approaches is available: (1) dialectical behavior therapy, mentalization-based therapy, schema focused therapy and transference focused therapy all proved beneficial in the treatment of borderline personality disorder. Cognitive-behavior therapy proved helpful in the treatment of (2) dissociative personality disorder and (3) avoidant personality disorder. There is limited evidence for interpersonal therapy and psychodynamic therapies in the treatment of avoidant personality disorder.     

Personality disorder diagnostic thresholds correspond to different levels of latent pathology

To meet a diagnosis for a particular personality disorder (PD), among other requirements, a person must exhibit a specified minimum number of the features outlined for that PD, otherwise referred to as the diagnostic threshold. Despite many years of research on the DSM PDs, there is little empirical basis for the chosen thresholds. The present study used mechanisms of item response theory (IRT) to link the diagnostic thresholds of six PDs to their corresponding level of latent PD pathology. Consistent with our hypothesis, analyses of the data from 41,227 participants revealed that PD diagnostic thresholds corresponded to a wide range of latent pathology. For example, the diagnostic threshold for schizoid PD corresponded to 1.54 SDs of pathology whereas the threshold for dependent PD corresponded to 2.72 SDs of pathology. The current analyses have demonstrated for the first time that the latent pathology associated with each PD threshold varies widely, and thus has quantified what others accurately have speculated. Implications and considerations for the future directions of PD classification are discussed.     

Sex Differences, Attributional Style, and Depressive Symptoms Among Adolescents

This study examined attributional style, sex, and depressive symptoms and diagnosis in high school students. The results revealed that (1) for females and males, higher levels of depressive symptoms correlated with a more depressive attributional style; (2) females and males who met diagnostic criteria for a current depressive disorder evidenced more depres-sogenic attributions than psychiatric controls, and never and past depressed adolescents; (3) although no sex differences in terms of attributional patterns for positive events, negative events, or for positive and negative events combined emerged, sex differences were revealed on a number of dimensional scores; (4) across the Children's Attributional Style Questionnaire (CASQ) subscale and dimensional scores, the relation between attributions and current self-reported depressive symptoms was stronger for females than males; and (5) no Sex × Diagnostic Group Status interaction effects emerged for CASQ subscale or dimensional scores. Implications of the complex findings from this large-scale, methodologically sophisticated study are addressed.     

An item response theory analysis of DSM-IV personality disorder criteria across younger and older age groups

Many of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV; American Psychiatric Association, 1994) personality disorder (PD) diagnostic criteria focus on a younger social and occupational context. The absence of age-appropriate criteria for older adults forces researchers and clinicians to draw conclusions based on existing criteria, which are likely inadequate. To explore which DSM-IV PD criteria contain age group measurement bias, the authors report 2 analyses of data on nearly 37,000 participants, ages 18-98 years, taken from a public data set that includes 7 of the 10 PDs (antisocial, avoidant, dependent, histrionic, obsessive-compulsive, paranoid, and schizoid). The 1st analysis revealed that older age groups tend to endorse fewer PD criteria than younger age groups. The 2nd analysis revealed that 29% of the criteria contain measurement bias. Although the latent variable structure for each PD was quite similar across younger and older age groups, some individual criteria were differentially endorsed by younger and older adults with equivalent PD pathology. The presence of measurement bias for these criteria raises questions concerning the assessment of PDs in older adults and the interpretation of existing data.