A critique of the proposed prototype rating system for personality disorders in DSM-5

The DSM-5 Personality and Personality Disorders (PDs) Work Group has recommended a reformulation of the PD section, one component of which is a replacement of specified operational criteria with a prototype matching dimensional rating system. The Work Group indicated that prototype ratings have been demonstrated to have good interrater reliability. No study was cited to support this statement, and a review of the reliability literature does not support this claim. The one study that directly compared the reliability of prototype and DSM-IV criteria counting approaches found the DSM-IV approach was much more reliably applied. The Work Group cited 2 studies supporting the validity of the prototype matching approach, one of which had significant methodological limitations and the other changed the a priori threshold on the PD prototype dimensional rating scale to categorize patients into PD positive and negative groups. The Work Group also cited 2 studies suggesting that prototype matching approaches are preferred by clinicians. Several studies have raised concerns about the adequacy of psychiatric diagnostic evaluations conducted in routine clinical practice thereby raising questions about the value of studies of clinicians' preferences in comparing different diagnostic practices. In conclusion, if the prototype matching dimensional approach described in the DSM-5 draft proposal is adopted, then it will have been adopted with essentially no empirical support demonstrating improved reliability or validity. In fact, there is evidence that reliability will be worse than the DSM-IV approach.     

Becoming an adult: A proposed typology of adult status based on a study of Spanish youths

Emerging adulthood is a transitional period which has been examined in relatively few studies in Southern European countries. This study has two aims: (1) to determine the features of emerging adulthood in Spain based on criteria for adulthood and experiential dimensions; and (2) to explore whether variations in these criteria are related to gender and adult status (self‐classification as an adult and adult role adoption). Participants included 347 young Spanish people, aged 18–30, who completed a questionnaire about their conceptions of adulthood. They used similar criteria for adulthood to other Western countries, placing an extremely strong emphasis on psychological maturity criteria in comparison with role transition indicators. Important variations were observed in both the importance and achievement of criteria for adulthood according to gender and adult status. The results likewise suggest there may be different psychosocial profiles associated with each adult status group. The relevance of this classification to future research in the field of emerging adulthood is discussed.     

Heritability of personality disorders in childhood: a preliminary investigation

The heritability of personality disorder features was investigated in 112 child (ages 4-15 years) twin pairs (70 monozygotic and 42 dizygotic pairs). Parents assessed personality disorder features using the Coolidge Personality and Neuropsychological Inventory for Children (CPNI; Coolidge, 1998) that measures 12 personality disorders according to the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 1994). Structural equation model-fitting methods indicated that the median heritability coefficient for the 12 scales was .75 (ranging from .81 for the Dependent and Schizotypal Personality Disorder scales to .50 for the Paranoid and Passive-Aggressive Personality Disorder scales). These results suggest that childhood personality disorders have a substantial genetic component and that they are similar to heritability estimates of personality disorder traits in adults and counter hypotheses that only temperaments and higher-order personality disorder traits have significant genetic components (Paris, 1997).     

A developmental typology of adolescent personality

The purpose of the current study is to examine whether Block's personality types (i.e. Resilients, Undercontrollers and Overcontrollers) are replicable as developmental trajectories. We applied a Latent Class Growth Analysis (LCGA) framework to five‐ annual‐wave data on a sample of early to middle adolescents (n = 923). Our results showed that Block's Resilients, Undercontrollers and Overcontrollers are indeed replicable as developmental trajectories across adolescence. These developmental types were related to problem behaviour in a similar way as types found in studies using cross‐sectional data. As such, Resilients reflected low levels of problem behaviour, Undercontrollers had high levels of delinquency and Overcontrollers had high levels of depression. Implications and suggestions for further research are discussed. Copyright © 2009 John Wiley & Sons, Ltd.     

A psychoanalytically informed hospitalization‐based treatment of personality disorders

This study presents a model of psychic change in personality disorders focusing on three dimensions: felt safety, mentalization and self‐object relations. Based upon this model a hospitalization‐based therapy program was created. Four scales to measure these three dimensions on the Object Relation Interview are discussed: the Felt Safety Scale, the Reflective Functioning Scale and the Bion Grid Scale and the Differentiation‐Relatedness Scale. A naturalistic symptom outcome study of the program showed a large effect on both symptoms and personality functioning. Furthermore, trajectory based on pre‐treatment patient characteristics (i.e., anaclitic versus introjective personality styles). Importantly, we also found a relation between symptomatic and personality change and change in felt safety and object relations. At 5‐year follow‐up, patients showed sustained improvement in symptomatic distress and further improvement in terms of personality and interpersonal functioning.     

Stimulus intensity control and personality: A research note

Previous research has suggested that variations in augmenting-reducing, extraversion, and sensation seeking might be explained in terms of a common stimulus intensity control mechanism. However, empirical tests of this hypothesized relationship have produced equivocal findings. The present study attempts to clarify the issue by analyzing scores for extraversion, sensation seeking, and both cortical and questionnaire measures of augmenting-reducing obtained from the same sample of subjects. Apart from a significant positive correlation between the questionnaire index of reducing and sensation seeking, which have not previously been investigated, the results show no evidence of a systematic relationship among the variables.     

Diagnosis of personality disorders: a case study

In this article, I report a case highlighting diagnostic uncertainty about psychopathology on both Axes I and II. It concerns in part the problem of comorbidity in relation to diagnostic classification of Axis II personality disorders. After commenting on these uncertainties in relation to categorical and dimensional models, I also consider a psychoanalytic explanation to illustrate an example in which a theoretical model informs diagnostic interviewing. I emphasize how the clinical information that unfolds from an interview based on this theoretical model generates inferences about psychopathology that extend clinical understanding beyond the formal diagnostic assessment of Axes I and II disorders and assessment by self-report.     

TIME RELATIONS IN DREAMS: A preliminary note

Examples are given of hypnotically induced dreams, which support the notion that series of experiences corresponding to long spans of objective time may be represented in dreams of very short duration. Both stimulus and organismic factors determine the contents of such dreams.     

The holistic theory of Andras Angyal: measuring the system principle

Scales were devised to measure Andras Angyal's concepts of the trends toward autonomy and homonomy and the patterns of vicarious living and noncommitment. In a sample of 82 undergraduates (62 women, 20 men), scores for the trends were negatively associated with psychoticism scores (-.42 and -.39, respectively), while scores for the patterns were positively associated with neuroticism scores (.42 and .49, respectively).     

Opinions of personality disorder experts regarding the DSM-IV personality disorders classification system

OBJECTIVE: To survey the opinions of personality disorder (PD) experts on possible revisions in the classification system for PDs in the DSM-V. METHOD: Four hundred members of two international associations, the Association for Research on Personality Disorders, and the International Society for the Study of Personality Disorders, were asked to take a 78-item web survey. RESULTS: Of the experts who completed the survey (N = 96), 74% felt that the DSM-IV's categorical system of PD diagnosis should be replaced. Eighty percent felt that PDs are better conceived of as personality dimensions or illness spectra, than as categories. The most frequently endorsed alternative system for PDs was a mixed system of categories and dimensions. Most experts preferred the PDs to remain on Axis II. Only 31.3% wanted the term, "Borderline Personality Disorder," retained in the DSM-V. CONCLUSIONS: A clear majority of the PD experts were dissatisfied with the current diagnostic system for PDs.     

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 note on preliminary tests of equality of variances

Preliminary tests of equality of variances used before a test of location are no longer widely recommended by statisticians, although they persist in some textbooks and software packages. The present study extends the findings of previous studies and provides further reasons for discontinuing the use of preliminary tests. The study found Type I error rates of a two‐stage procedure, consisting of a preliminary Levene test on samples of different sizes with unequal variances, followed by either a Student pooled‐variances t test or a Welch separate‐variances t test. Simulations disclosed that the twostage procedure fails to protect the significance level and usually makes the situation worse. Earlier studies have shown that preliminary tests often adversely affect the size of the test, and also that the Welch test is superior to the t test when variances are unequal. The present simulations reveal that changes in Type I error rates are greater when sample sizes are smaller, when the difference in variances is slight rather than extreme, and when the significance level is more stringent. Furthermore, the validity of the Welch test deteriorates if it is used only on those occasions where a preliminary test indicates it is needed. Optimum protection is assured by using a separate‐variances test unconditionally whenever sample sizes are unequal.     

Beliefs in personality disorders: a test with the personality disorder belief questionnaire

The hypothesis that each personality disorder (PD) is characterized by a specific set of beliefs was tested in a sample of 643 subjects, including non-patient controls, axis-I and axis-II patients, diagnosed with SCID-I and -II interviews. Beliefs of six PDs (avoidant, dependent, obsessive-compulsive, paranoid, histrionic, borderline) were assessed with the Personality Disorder Belief Questionnaire (PDBQ). Factor analyses supported the existence of six hypothesized sets of beliefs. Structural equation modeling (SEM) supported the hypothesis that each PD is characterized by a specific set of beliefs. Path coefficients were however in the medium range, suggesting that PDs are not solely determined by beliefs. Nevertheless, empirically derived cutoff scores of the six belief subscales were reasonably successful in classifying subjects, percentages ranging form 51% to 83%. It appeared that there was a monotonical increase in scores on each belief subscale from non-patient controls, to patients without any PD, to patients with PDs (other than the pertinent PD), to patients with the pertinent PD. This suggests that PD-related beliefs are at least partly associated with (personality) psychopathology in general. Another explanation is that many patients' position on the underlying dimensions is not high enough to lead to a DSM PD diagnosis, but high enough to lead to an elevated belief score.