An empirical test of schema mode conceptualizations in personality disorders

Although the use of schema modes in schema-focused therapy (SFT) has been very popular since its introduction, Young's schema mode concept remained largely empirically untested. In order to provide insight into the mode conceptualization of personality disorders (PDs), the current study assessed the relationships between 14 schema modes and all PDs. Relationships between dimensional PD scores and self-reported mode scores were tested in a mixed study group of 489 participants, consisting of axis I and axis II patients, and non-patients. Psychopathology was assessed by means of the Structured Clinical Interview for DSM-IV axis I and axis II disorders (SCID I and SCID II) or the Structural Interview for DSM-IV Personality Disorders (SIDP-IV), and modes were assessed by the Schema Mode Inventory. Kendall's partial tau coefficients, controlling each PD-mode correlation for all other PD scores, indicated unique mode profiles for all PDs and corroborated most of the hypothesized PD-mode correlations, supporting the construct validity of the mode model. Nevertheless, the high number of correlations found for some PDs raises concerns about the specificity of the mode model. Implications for both research and therapy are discussed.     

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.     

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.     

The association between axis I and II psychiatric symptoms and high-risk sexual behavior during adolescence

This study was conducted to investigate the association between psychiatric disorders and high-risk sexual behavior among adolescent primary care patients. Interviews assessing anxiety, conduct, depressive, eating, substance use, and personality disorders (PDs), as well as histories of sexual behavior were administered to 119 male and 284 female adolescent primary care patients. Results indicated that, after co-occurring psychiatric disorders were controlled statistically, adolescents with elevated PD symptom levels were more likely than adolescents without elevated PD symptom levels to report a high number of sexual partners during the past year and during their lifetime. Adolescents with a history of conduct disorder were more likely than adolescents without such a history to report a high number of lifetime unsafe sexual partners. Elevated antisocial, dependent, and paranoid PD symptom levels were associated with high-risk sexual behavior after co-occurring psychiatric disorders were controlled. Further, certain specific antisocial, borderline, dependent, histrionic, narcissistic, obsessive-compulsive, paranoid, and schizotypal PD symptoms were independently associated with high-risk sexual behavior after co-occurring psychiatric disorders and overall PD symptom levels were controlled. The association between overall PD symptom levels and the number of sexual partners was significantly stronger among the females than among the males in the sample. Increased recognition and treatment of PDs, coupled with increased recognition of high-risk sexual behavior may facilitate the prevention of sexually transmitted diseases and teenage pregnancy among adolescents.     

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.     

Perceptions of people with personality disorders based on thin slices of behavior

Strangers made reliable judgments about personality traits after viewing one 30-s excerpt from interviews with anonymous target persons. Ratings were generated for 229 military recruits participating in a study of personality disorders. Approximately 28% of the recruits met DSM-IV criteria for a definite or probable personality disorder (PD). Several untrained undergraduate students rated each video clip with regard to the Big Five personality traits, physical attractiveness, and likeability. The students accurately rated people who exhibited features of paranoid, schizotypal, dependent, and avoidant PDs as being lower in extraversion. The raters also considered these people less likeable. Students accurately rated people who exhibited features of histrionic PD as being higher in extraversion and found them to be more likeable. Laypersons can make accurate judgments regarding some personality characteristics associated with personality disorders, even on the basis of minimal information. These perceptions may influence ways in which people respond to others with PDs.     

Conceptualizations of Personality Disorders with the Five Factor Model-count and Empathy Traits

Previous research has long advocated that emotional and behavioral disorders are related to general personality traits, such as the Five Factor Model (FFM). The addition of section III in the latest Diagnostic and Statistical Manual of Mental Disorders (DSM) recommends that extremity in personality traits together with maladaptive interpersonal functioning, such as lack of empathy, are used for identifying psychopathology and particularly personality disorders (PD). The objective of the present study was to measure dispositions for DSM categories based on normal personality continuums, and to conceptualize these with empathy traits. We used a validated FFM-count method based on the five personality factors (neuroticism, extraversion, openness, agreeableness, and conscientiousness), and related these to 4 empathy traits (emphatic concern, perspective-taking, fantasy, and personal distress). The results showed that FFM-based PD scores overall could be conceptualized using only two of the empathy traits, low emphatic concern and high personal distress. Further, specific dispositions for personality disorders were characterized with distinct empathy traits (e.g., histrionic with high fantasy, and paranoid with low perspective-taking). These findings may have both theoretical and practical implications in capturing potential for personality disorders with ease and efficiency.     

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.     

Schematherapie bei antisozialem Verhalten und Psychopathie

In the Netherlands schema therapy is the first evidence-based treatment to be recommended for patients with personality disorders in forensic settings. Initial results show that schema therapy can even be effective in cases of “psychopathy”. The central concept in schema therapy are schema modes which can also be seen as emotional states or “parts of the personality”, which dominate temporary thoughts, emotions and behavior. Schema modes are the basis of individual mode models, which guide understanding and treatment of the disorder throughout the complete therapy. The schema therapeutic analysis of delinquency is part of the schema mode model and connects the sequences of the crime with the offender’s schema modes. With respect to the mode treatment, emotion-focused techniques and the therapeutic relationship are of special importance. The schema therapeutic treatment plan combines short-term behavior-related therapeutic goals with the underlying themes (needs and modes) in order to plan concrete interventions based on this. This has to be embedded into the individual structure of therapeutic options in the respective institutions (e.?g. individual psychotherapy, nursing staff, occupational therapy). This article demonstrates the practice of the schema therapeutic approach with a forensic case study and discusses resources and limits of the schema therapeutic approach in a forensic setting.     

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).     

The association of affiliation and achievement personality styles with DSM-IV personality disorders

Investigators from theoretically diverse backgrounds have long described two personality styles associated with depression. The affiliation style describes individuals with interpersonal concerns; the achievement style describes individuals who have concerns with personal failure. Although primarily related to risk for depression, there has also been recognition that extreme forms of these styles are related to personality disorders (PDs). The current study examines the relation between the DSM-IV PDs and the two personality styles, assessing the latter using two approaches: (a) dependency/self-criticism (Blatt, 1974) and (b) sociotropy/autonomy (Beck, 1983). Results show that whereas the achievement style is associated with most PDs (except for the histrionic and dependent PDs), the affiliation style is associated only with histrionic, dependent, and depressive PDs. Controlling for shared PD variance leaves only two associations, affiliation with dependent PD and achievement with narcissistic PD. Results are discussed in the context of current efforts to capture personality psychopathology within a comprehensive dimensional framework.     

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.     

Comorbidity of Personality Disorders and Somatization Disorder: A Meta-analytic Review

Meta-analysis of studies assessing the comorbidity of somatization disorder (SD) with one or more personality disorders (PDs) revealed that-contrary to the assertions of the Diagnostic and Statistical Manual of Mental Disorders (4th edition, text revision)-SD co-occurs with the majority of Axis II PDs. Although comorbidity effect sizes (rs) linking SD with paranoid PD and obsessive-compulsive PD were small, effect sizes for antisocial, borderline, narcissistic, histrionic, avoidant, and dependent PD yielded rs about or above 0.20. Comorbidity information in future versions of the DSM should be revised to reflect the greater number of PDs empirically linked with SD.

Beyond dysfunction and threshold-based classification: a multidimensional model of personality disorder diagnosis

An alternative dimensional model of personality disorder (PD) diagnosis that addresses several difficulties inherent in the current DSM conceptualization of PDs (excessive PD overlap and comorbidity, use of arbitrary thresholds to distinguish normal from pathological personality functioning, failure to capture variations in the adaptative value of PD symptoms, and inattention to the impact of situational influences on PD-related behaviors) is outlined. The model uses a set of diagnostician-friendly strategies to render PD diagnosis in three steps: (1) the diagnostician assigns every patient a single dimensional rating of overall level of personality dysfunction on a 50-point continuum; (2) the diagnostician assigns separate intensity and impairment ratings for each PD dimension (e.g., narcissism, avoidance, dependency); and (3) the diagnostician lists any personality traits-including PD-related traits-that enhance adaptation and functioning (e.g., histrionic theatricality, obsessive attention to detail). Advantages of the proposed model for clinicians and clinical researchers are discussed.     

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.     

Assumptions in borderline personality disorder: specificity, stability and relationship with etiological factors.

The specificity and stability of a set of assumptions hypothesized to be characteristic of Borderline Personality Disorder (BPD) was investigated. BPD patients (n = 16) were compared to cluster-C personality disorder patients (n = 12) and to normal controls (n = 15). All subjects were female and diagnosed with SCID-I and -II. Subjects rated a short version of the Personality Disorder Beliefs Questionnaire (PDBQ), with six sets of 20 assumptions each, hypothesized to be characteristic of avoidant, dependent, obsessive-compulsive, paranoid, histrionic and borderline personality disorder. The BPD assumptions (Cronbach alpha = 0.95) proved to be the most specific to BPD patients. Subjects rated the shortened PDBQ again after viewing an emotional video fragment one week later. Despite increased negative emotions, the PDBQ ratings remained relatively stable. Confirming the cognitive hypothesis, regression analyses indicated that the BPD assumptions mediate the relationship between self-reported etiological factors from childhood (sexual abuse and emotional/physical abuse) and BPD pathology assessed with the SCID-II. It is suggested that a set of assumptions is characteristic of BPD, and is relatively stable despite the instability of the behaviour of people diagnosed as having BPD.     

Personality Disorders and Spinal Cord Injury: A Pilot Study

A substantial body of research has found that spinal cord injury (SCI) patients have relatively high degrees of energy, impulsivity, and risk-taking (W. Fordyce, 1964; G. P. Taylor, 1970; B. Woodbury, 1978). The present study endeavors to extend our knowledge to the personality disorder (PD) domain. Forty SCI participants and 40 matched controls were given a semistructured diagnostic interview and a self-report personality disorder instrument. Findings indicated that 27.5% of SCI patients, and a similar number of controls, have PDs. Unexpectedly, impulsive/externalizing disorders (histrionic, narcissistic, antisocial, and borderline) were not unusually high in SCI patients, and were not higher than controls. Avoidant and depressive disorders were unexpectedly high.     

Day treatment of patients with personality disorders: experiences from a Norwegian treatment research network

This study sought to investigate the following research questions: Are time-limited day treatment programs for patients with personality disorder (PD) effective outside resourceful university settings, and what are the overall treatment results when the program is implemented on a larger scale? Do all categories and subtypes of PDs respond favorably to such treatment? How intensive should such day treatment programs be? All patients (n = 1,244) were consecutively admitted to eight different treatment programs in the Norwegian Network of Psychotherapeutic Day Hospitals from 1993 to 2000. Altogether, 1,010 patients were diagnosed with PD. Avoidant, borderline, not otherwise specified (NOS), and paranoid PD were the most common conditions. SCID-II and MINI were used as diagnostic instruments. Outcome measures included GAF Global Assessment of Functioning, (GAF; American Psychiatric Association, 1994), SCL-90R, CIP, Quality of Life, work functioning and parasuicidal behavior, measured at admittance, discharge and 1-year follow up. The attrition rate was 24%. The number of dropouts did not improve over time. As a group, completers with PD improved significantly on all outcome variables from admittance to discharge and improvement was maintained or increased at follow up. Treatment results were best for borderline PD, cluster C patients, PD NOS and No PD, and poorer for cluster A patients. Units with a high treatment dosage did not experience better outcomes than those with a low treatment dosage (10 hours per week). Results from the University unit were not better than those from units at local hospitals or mental health centers.     

Rorschach aggression variables: a study of reliability and validity

This study investigated the extent to which 6 Rorschach variables of aggression (A1, A2, AG, MOR, AgC, AgPast) are related to one another, to the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) Cluster B personality disorder criteria, and to self-report measures of anger, aggression, and antisocial behavior. Seventy-eight patients were found to meet DSM-IV criteria for an Axis II disorder, Cluster A personality disorder (paranoid, schizoid, schizotypal) = 9, Cluster B (antisocial personality disorder [ANPD] = 16, borderline personality disorder [BPD] = 23, histrionic personality disorder = 5, narcissistic personality disorder = 12) = 56, and Cluster C personality disorder (avoidant, dependent, obsessive-compulsive) = 13. The results of this study indicated that (a) these 6 Rorschach aggression variables can be scored reliably; (b) 2 factors, revealed by factor analysis, accounted for 77% of the total variance; (c) selected variables were found to be empirically related to DSM-IV diagnostic criteria for ANPD and BPD; and (d) selected variables were found to be empirically related to a self-report measure of anger and antisocial practices. The conceptual nature and clinical utility of these Rorschach aggression variables as well as implications for future research are discussed.