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.     

Predicting DMS-IV cluster B personality disorder criteria from MMPI-2 and Rorschach data: a test of incremental validity

Despite their frequent conjoint clinical use, the incremental validity of Rorschach (Rorschach, 1921/1942) and MMPI (Hathaway & McKinley, 1943) data has not been adequately established, nor has any study to date explored the incremental validity of these tests for predicting Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) personality disorders (PDs). In a reanalysis of existing data, we used select Rorschach variables and the MMPI PD scales to predict DSM-IV antisocial, borderline, histrionic, and narcissistic PD criteria in a sample of treatment-seeking outpatients. The correlational findings revealed alimited relation between Rorschach and MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) variables, with only 5 of 30 correlations reaching significance (p <.05). Hierarchical regression analyses showed that both the MMPI and Rorschach data add incrementally in the prediction of DSM-IV borderline and narcissistic PD total criteria scores. The findings were less clear for the incremental value of Rorschach and MMPI-2 data in predicting the total number of DSM-IV histrionic PD criteria, which were best predicted by Rorschach data, and antisocial PD criteria, which were best predicted by MMPI-2 data. In addition to providing evidence of the incremental validity of Rorschach data, these findings also shed light on the psychological characteristics of the DSM-IV Cluster B PDs.     

Predicting DSM-IV Cluster B Personality Disorder Criteria From MMPI-2 and Rorschach Data: A Test of Incremental Validity

Despite their frequent conjoint clinical use, the incremental validity of Rorschach (Rorschach, 1921/1942) and MMPI (Hathaway & McKinley, 1943) data has not been adequately established, nor has any study to date explored the incremental validity of these tests for predicting Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) personality disorders (PDs). In a reanalysis of existing data, we used select Rorschach variables and the MMPI PD scales to predict DSM-IV antisocial, borderline, histrionic, and narcissistic PD criteria in a sample of treatment-seeking outpatients. The correlational findings revealed a limited relation between Rorschach and MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) variables, with only 5 of 30 correlations reaching significance (p < .05). Hierarchical regression analyses showed that both the MMPI and Rorschach data add incrementally in the prediction of DSM-IV borderline and narcissistic PD total criteria scores. The findings were less clear for the incremental value of Rorschach and MMPI-2 data in predicting the total number of DSM-IV histrionic PD criteria, which were best predicted by Rorschach data, and antisocial PD criteria, which were best predicted by MMPI-2 data. In addition to providing evidence of the incremental validity of Rorschach data, these findings also shed light on the psychological characteristics of the DSM-IV Cluster B PDs.     

Age Neutrality of Categorically and Dimensionally Measured DSM–5 Section II Personality Disorder Symptoms

Studies on the face validity of DSM–5 Section II categorical personality disorder (PD) symptoms indicate a bias against older adults. To extend these results, this article explores whether categorically and dimensionally scored PD symptoms of DSM–5 Section II, as measured in the Assessment of DSM–IV Personality Disorders (ADP–IV; Schotte & de Doncker, 1994), corroborate potential age bias across younger (aged 18–34), middle-aged (35–59 years), and older adults (aged 60–75). Differential item functioning (DIF) analyses, following a classical test theory approach, showed that 2 of the 79 symptoms were measured differently across 3 age groups when categorically assessed, and 4 when dimensionally measured. Nevertheless, subsequent differential test functioning analyses supported a low aggregated impact of DIF on the dimensional scales, justifying mean-level comparisons across age groups. Generalizability of the results is discussed in light of methodological issues concerning the research of age neutrality of PD symptoms, including the employed measurement instrument, PD symptom measurement approach, and sample and age range used to describe older adults.     

Confirmatory factor analyses of DSM-IV Cluster C personality disorder criteria

Notwithstanding its research and clinical relevance, the dimensionality and validity of the DSM-IV avoidant, dependent, and obsessive-compulsive personality disorders (PDs) criteria is still a largely unexplored topic. The aim of this study was to test the factor structure for DSM-IV Cluster C PD criteria in a sample of 641 consecutively admitted outpatients. Factor analysis results suggested that avoidant, dependent, and obsessive-compulsive PDs share a common latent dimension, and supported the three-factor structure of both observer and self-report ratings of DSM-IV Cluster C PD criteria. The pattern of factor loadings, however, was different from the one expected according to the DSM-IV classification.     

Development and validation of a new procedure for the diagnostic assessment of personality disorder: the Multidimensional Personality Disorder Rating Scale (MPDRS)

Data from a community-based prospective longitudinal study were used to investigate the utility of a structured assessment of the DSM-IV General Diagnostic Criteria for a Personality Disorder (PD). The Structured Clinical Interview for DSM-IV PDs (SCID-II) was administered to 154 adults. After completing the interview, an experienced clinician assessed the General Diagnostic Criteria for a PD using a structured rating scale. PD diagnoses, based solely on the rating scale data, demonstrated strong agreement with diagnoses obtained using the diagnostic thresholds for specific PDs (Kappa = 0.89). The sensitivity, specificity, predictive power, and internal reliability of the rating scale were satisfactory. PD diagnoses, based on both of the assessment procedures, were associated with substantial impairment and distress. These findings suggest that a structured assessment of the DSM-IV General Diagnostic Criteria for a Personality Disorder may constitute a useful alternative or supplement to standard assessments of the diagnostic thresholds for specific DSM-IV PDs.     

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.     

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).     

Distinguishing general and specific personality disorder features and implications for substance dependence comorbidity

Clinical and population-based samples show high comorbidity between Substance Use Disorders (SUDs) and Axis II Personality Disorders (PDs). However, Axis II disorders are frequently comorbid with each other, and existing research has generally failed to distinguish the extent to which SUD/PD comorbidity is general or specific with respect to both specific types of PDs and specific types of SUDs. We sought to determine whether ostensibly specific comorbid substance dependence-Axis II diagnoses (e.g., alcohol use dependence and borderline personality disorder) are reflective of more pervasive or general personality pathology or whether the comorbidity is specific to individual PDs. Face-to-face interview data from Wave 1 and Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions were analyzed. Participants included 34,653 adults living in households in the United States. We used hierarchical factor models to statistically partition general and specific personality disorder dimensions while simultaneously testing for specific PD-substance dependence relations. Results indicated that substance dependence-Axis II comorbidity is characterized by general (pervasive) pathology and by Cluster B PD pathology over and above the relationship to the general PD factor. Further, these relations between PD factors and substance dependence diagnoses appeared to largely account for the comorbidity among substance dependence diagnoses in the younger but not older participants. Our findings suggest that a failure to consider the general PD factor, which we interpret as reflecting interpersonal dysfunction, can lead to potential mischaracterizations of the nature of certain PD and SUD comorbidities.     

Hindsight bias from 3 to 95 years of age

Upon learning the outcome to a problem, people tend to believe that they knew it all along (hindsight bias). Here, we report the first study to trace the development of hindsight bias across the life span. One hundred ninety-four participants aged 3 to 95 years completed 3 tasks designed to measure visual and verbal hindsight bias. All age groups demonstrated hindsight bias on all 3 tasks; however, preschoolers and older adults exhibited more bias than older children and younger adults. Multinomial processing tree analyses of these data revealed that preschoolers' enhanced hindsight bias resulted from them substituting the correct answer for their original answer in their recall (a qualitative error). Conversely, older adults' enhanced hindsight bias resulted from them forgetting their original answer and recalling an answer closer to, but not equal to, the correct answer (a quantitative error). We discuss these findings in relation to mechanisms of memory, perspective taking, theory of mind, and executive function.     

Personality disorders in the elderly compared to four younger age groups: a cross-sectional study of community residents and mental health patients

The notion is expressed in the DSM-IV that some personality disorders (PDs) tend to remit with age whereas other types do not. This notion is supported by the literature and the study reported here. Studies published between 1951 and 2000 show that (1) in old age, PDs are prevalent both in normal subjects and to a greater extent in the mentally ill; (2) the evidence for general age-relatedness of PDs is scarce and contradictory; (3) there is evidence for specific age-relatedness of PDs in old age. This empirical study focused on the prevalence of PDs in five different age groups ranging from adolescence to old age. It included both community residents (N = 623, aged 17-87), and mental health patients (N = 315, aged 18-86). Dimensional scores for PDs were assessed by means of the DSM-III-R- and ICD-10- based self-report Questionnaire of Personality Traits (VKP) (Duijsens, Eurelings-Bontekoe & Diekstra, 1996). There was consistent evidence for a specific effect of aging: community residents in the oldest age group reported more schizoid and more obsessive-compulsive characteristics compared to one or more of the younger age groups. Older mental health patients showed more schizoid disorder characteristics and fewer high-energy disorder characteristics compared to one or more of the younger patient groups.     

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.     

A Comparison of the Factorial Structure of DSM-IV Criteria for Generalized Anxiety Disorder Between Younger and Older Adults

The controversy concerning the validity and reliability of generalized anxiety disorder (GAD) appears to be particularly relevant in the elderly, since physical symptoms associated with GAD can readily be considered as the consequences of normal aging. This study aims to analyze the structure invariance of a questionnaire assessing the DSM-IV diagnostic criteria across samples of older adults and college students. Ninety-seven adults aged 65 or over and 130 college students completed the Worry and Anxiety Questionnaire (WAQ). The results revealed that factorial invariance could be assumed and, in addition, that scores for severity of GAD symptoms were higher in younger subjects than in older ones. The results support the applicability of DSM-IV criteria for GAD in elderly people, as the factorial structure of the WAQ was the same for this age group as for younger adults. A higher degree of GAD severity was found in the younger sample.

Two-year stability of personality disorder in older adolescent outpatients

The 2-year stability of categorical and dimensional personality disorder (PD) in an older adolescent psychiatric outpatient sample was examined. One hundred and one 15-18-year-old participants were assessed using the Structured Clinical Interview for DSM Axis II Disorders (SCID-II) at baseline and 97 were re-interviewed, face-to-face, at 2 years. Of those with a categorical PD diagnosis at baseline, 74% still met criteria for a PD at follow-up, with marked gender differences (83% of females and 56% of males). Kappa for specific PDs was low for all except antisocial. Rank order and mean level dimensional stability ranged from high (antisocial, schizoid) to moderate (borderline, histrionic, schizotypal) to low (other PDs), with no decline in PD scores over the 2 years. There was no substantial influence upon stability of dimensional PD from the presence of Axis I disorder at baseline or from outpatient or inpatient treatment. However, categorical PD endured in 100% of those receiving inpatient care. The study supports that, in late teenage outpatients, the 2-year stability of the global category of PD is high and the stability of dimensionally rated PD appears to be similar to that found in young adults in a variety of settings, especially for some cluster A and B PDs. Diagnosis and early intervention appears to be justified in this age group.     

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.     

The role of vocabulary ability during visual word recognition in younger and older adults

The role that vocabulary ability plays in adult age differences in word recognition was investigated. In Experiment 1, 44 older adults (ages 61-93 years) were compared with 44 younger adults (ages 18-39 years) on a standard lexical-decision task, with ambiguous words, unambiguous words, and pseudowords serving as stimuli. In Experiment 1, the Wechsler Adult Intelligence Scale-Revised (WAIS-R; D. Wechsler, 1981) vocabulary performance was uncontrolled across the younger and older adults, and the older adults had higher WAIS-R scores. There was no Group x Stimulus interaction. In Experiment 2, the data from the same 44 older adults were compared with data from a new sample of 44 younger adults (ages 18-44). Both groups were then matched on WAIS-R performance. Results revealed a significant Group x Stimulus interaction. Reaction time differences between the younger and older groups on the ambiguous words and unambiguous words were identical. The differences in reaction times for words and pseudowords were greater in the older adults. The importance of vocabulary ability during word recognition and lexical processing is discussed.     

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.     

Severity of childhood attention-deficit hyperactivity disorder--a risk factor for personality disorders in adult life?

Some evidence points to an increased rate of cluster B and C personality disorders (PDs) in adult ADHD patients. In order to assess axis II disorders comprehensively we used the diagnostic instrument of the WHO. In sixty adult out-patients with ADHD according to DSM-IV criteria PDs were assessed with the International PD Examination (IPDE) and severity of childhood ADHD with the Wender-Utah-Rating Scale (WURS). We found at least one PD in 25% of cases. Cluster C PDs were most common (36.6%) followed by Cluster B (23.3%) and A (8.3%). Avoidant (21.7%) and borderline (18.3%) were the most frequent single PD entities. ADHD patients with PD suffered from significantly more severe childhood ADHD compared to those without co-occurring PD. Applying the IPDE we confirmed a high number of PDs among adult ADHD patients. Our findings point to a higher vulnerability for the development of PDs in patients with severe childhood ADHD.