Differentiation of Axis I and Axis II disorders

The revised 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1987) distinguishes between Axis I and Axis II disorders: Axis II includes personality (and developmental) disorders, and all others are on Axis I. This distinction is often useful, but the reification of Axis I and II constructs through diagnostic criteria sets that demarcate categorically distinct entities is at times problematic. We review the issues of differentiating personality from Axis I disorders, specifically illustrated by schizotypal and schizophrenic disorders, borderline and mood disorders, antisocial and substance use disorders, and avoidant personality from social phobia. The options for addressing their differentiation include adding exclusion criteria, shifting the placement of disorders, deleting overlapping criteria, adding differentiating criteria, and converting to a dimensional format.     

Stability as a distinction between Axis I and Axis II disorders

Temporal stability has served as a conceptual basis for the distinction between the clinical syndromes of Axis I disorders and the Axis II personality disorders, the latter being viewed as lifelong enduring patterns. However, comparisons of the stability of Axis I and II disorders have been limited. The present review examines findings from three naturalistic longitudinal studies that utilize similar methodology: the Collaborative Longitudinal Personality Disorders Study (CLPS; Gunderson et al., 2000), the Collaborative Depression Study (CDS; Katz & Klerman, 1979), and the Harvard/Brown Anxiety Research Program (HARP; Keller et al., 1994). Using a definition of remission/recovery as having no or minimal symptoms for 8 consecutive weeks, the courses of personality, depressive, and anxiety disorders were compared. Though remission/recovery rate at the 2-year follow-up was highest for mood disorders, the probability of recurrence was also particularly high. Personality disorders, with remission rates higher than the anxiety disorders, appear to be less stable than conceptualized. The anxiety disorders had remarkably low recovery rates even beyond 5 years of prospective follow-up. Factors that may explain these findings, as well as implications for future conceptualization of DSM, are discussed.     

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.     

Personality disorder and Axis I psychopathology: the problematic boundary of Axis I and Axis II

The confusion of personality disorders with Axis I disorders can be traced in part to inadequacies of assessment instruments and diagnostic criterion sets. However, it also reflects the absence of adequate conceptualization. If Axis I continues to include early onset, chronic impairments that characterize everyday functioning, then there is unlikely to be a clear or meaningful distinction. Inherent and unique to personality disorders is that they concern a person's sense of self and identity. They are disorders of everyday functioning. Personality disorders have an early onset, characterize everyday functioning, and relate closely to personality functioning evident within the general population; Axis I disorders, in contrast, have an onset throughout adult life, are episodic, and are readily distinguishable from normal personality functioning.     

Associations in the course of personality disorders and Axis I disorders over time

In this study, the authors examined time-varying associations between schizotypal (STPD), borderline (BPD), avoidant (AVPD), or obsessive-compulsive (OCPD) personality disorders and co-occurring Axis I disorders in 544 adult participants from the Collaborative Longitudinal Personality Disorders Study. The authors tested predictions of specific longitudinal associations derived from a model of crosscutting psychobiological dimensions (L. J. Siever & K. L. Davis, 1991) with participants with the relevant Axis I disorders. The authors assessed participants at baseline and at 6-, 12-, and 24-month follow-up evaluations. BPD showed significant longitudinal associations with major depressive disorder and posttraumatic stress disorder. AVPD was significantly associated with anxiety disorders (specifically social phobia and obsessive-compulsive disorder). Two of the four personality disorders under examination (STPD and OCPD) showed little or no association with Axis I disorders.     

Social phobia: Axis I and II correlates

The presence of Axis I and Axis II disorders in 71 social phobic patients was examined. Generalized anxiety disorder was the most common secondary Axis I disorder, followed by simple phobia. Avoidant personality disorder and obsessive-compulsive personality disorder were the most common Axis II diagnoses, and 88% of the sample exhibited features of these 2 personality styles. Subjects with additional Axis I diagnoses were more anxious and depressed than those with no additional Axis I disorder. Social phobics with additional Axis II disorders were more depressed but not more anxious than those with no Axis II diagnosis. Furthermore, those with an additional Axis I disorder had higher scores on measures of neuroticism, interpersonal sensitivity, and agoraphobia. The prevalence and impact of additional Axis I and II disorders on the etiology, maintenance, and treatment outcome for persons with social phobia are discussed.     

Axis I and axis II disorders as predictors of prospective suicide attempts: findings from the collaborative longitudinal personality disorders study

This study examined diagnostic predictors of prospectively observed suicide attempts in a personality disorder (PD) sample. During 2 years of follow-up, 58 participants (9%) reported at least 1 definitive suicide attempt. Predictors that were examined include 4 PD diagnoses and selected Axis I diagnoses (baseline and course). Multivariate logistic regression analyses indicated that baseline borderline personality disorder (BPD) and drug use disorders significantly predicted prospective suicide attempts. Controlling for baseline BPD diagnosis, proportional hazards analyses showed that worsening in the course of major depressive disorder (MDD) and of substance use disorders in the month preceding the attempt were also significant predictors. Therefore, among individuals diagnosed with PDs. exacerbation of Axis I conditions, particularly MDD and substance use, heightens risk for a suicide attempt.     

Axis I anxiety and mental health disorders among stuttering adolescents

PurposeThe purpose of this study was to evaluate anxiety and psychological functioning among adolescents seeking speech therapy for stuttering using a structured, diagnostic interview and psychological questionnaires. This study also sought to determine whether any differences in psychological status were evident between younger and older adolescents.MethodParticipants were 37 stuttering adolescents seeking stuttering treatment. We administered the Computerized Voice Version of the Diagnostic Interview Schedule for Children, and five psychometric tests. Participants were classified into younger (12–14 years; n = 20) and older adolescents (15–17 years; n = 17).ResultsThirty-eight percent of participants attained at least one diagnosis of a mental disorder, according to the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; APA, 2000), with the majority of these diagnoses involving anxiety. This figure is double current estimates for general adolescent populations, and is consistent with our finding of moderate and moderate–severe quality of life impairment. Although many of the scores on psychological measures fell within the normal range, older adolescents (15–17 years) reported significantly higher anxiety, depression, reactions to stuttering, and emotional/behavioral problems, than younger adolescents (12–14 years). There was scant evidence that self-reported stuttering severity is correlated with mental health issues. There are good reasons to believe these results are conservative because many participants gave socially desirable responses about their mental health status.DiscussionThese results reveal a need for large-scale, statistically powerful assessments of anxiety and other mental disorders among stuttering adolescents with reference to control populations.Educational Objectives: The reader will be able to: (a) explain the clinical importance of assessing for mental health with stuttering adolescents, (b) state the superior method for adolescent mental health assessment and (c) state a major issue with determining the genuineness of stuttering adolescent responses to psychological assessment.     

Axis I and II comorbidity in adults with ADHD

Ongoing debate over the validity of the attention-deficit/hyperactivity disorder (ADHD) construct in adulthood is fueled in part by uncertainty regarding implications of potentially extensive yet incompletely described comorbid Axis I and II psychopathology. Three hundred sixty-three adults ages 18 to 37 completed semistructured clinical interviews; informants were also interviewed, and best estimate diagnoses were obtained. Results were as follows: First, ADHD combined type (ADHD-C) had an excess of externalizing and internalizing Axis I disorders, suggesting a gradient-of-severity relationship between it and ADHD inattentive type (ADHD-I). Second, ADHD-C and ADHD-I did not differ in frequency of Axis II disorders. Third, however, ADHD overall was associated with increased rates of Axis II disorders, compared with rates in non-ADHD control participants, including both Cluster B (primarily borderline personality disorder) and Cluster C disorders. Fourth, ADHD incrementally accounted for clinician-rated global assessment of functioning scores above and beyond comorbid conditions or symptoms on either Axis I or Axis II. Results further inform nosology of ADHD in adults.     

Dimensions of DSM-IV personality disorders and life-success

This study examined associations between dimensional representations of DSM-IV personality disorders and life-success in a community sample of 304 men at age 48. Measures included a standardized social interview and the SCID-II for assessment of personality disorders. The identified indicators of life-success were factor-analyzed resulting in two moderately correlated components representing "status and wealth" and "successful intimate relationships." Avoidant, obsessivecompulsive, and narcissistic dimensional scores were positively associated with "status and wealth." Inverse relationships were found between dependent, schizotypal, schizoid, and adult antisocial personality disorder dimensions and this domain of life-success. Avoidant, schizoid, and borderline personality disorder dimensions were negatively associated with "successful intimate relationships." The findings suggest that although most personality disorders are associated with impaired psychosocial functioning and life-failure, some personality disorder traits (even if considered as pathological) can contribute positively to one important aspect of life-success: status and wealth.     

The effect of Axis II disorders on the outcome of treatment of anxiety and unipolar depressive disorders: a review

Psychiatric and other clinicians have often speculated on whether the presence of a personality disorder would indicate a poorer course of treatment for an Axis I disorder. Starting around 1990, the standardized criteria of the DSM increased interest in examining this area empirically. This report updates my previous reviews and examines other writing in this area. There is still a considerable body of evidence indicating that personality may cause a poorer treatment outcome of an Axis I disorder; however, there are also intriguing new developments. The introduction of new drug treatments that may be helpful with some dysfunctional personality traits changes some of the findings and may suggest that there may be preferential treatments for some Axis I patients with certain comorbid personality traits. (In certain cases this may apply to some specific psychotherapy techniques as well.) In addition, at times, personality traits may predict a positive outcome to treatment. This review is an attempt to bring together this diverse area and suggest where fruitful areas of research and intervention may possibly be found.     

The structure of personality disorders: comparing the DSM-IV-TR Axis II classification with the five-factor model framework using structural equation modeling

Earlier factor analytical studies on the empirical validity of the DSM-IV-TR (American Psychological Association, 2000) Axis II classification have offered little support for the current three-cluster structure. In his large-scale meta-analysis of previously published personality disorder correlation matrices, O'Connor (2005) found four factors, corresponding to the neuroticism, extraversion, agreeableness, and conscientiousness domains of the five-factor model of personality. In the present study, this dimensional four-factor model and the categorical DSM three-cluster structure were fitted to the Assessment of DSM-IV Personality Disorders questionnaire (ADP-IV; Schotte & De Doncker, 1994) scale scores using structural equation modelling. The results strongly favored the dimensional model, which also resembled other well-founded four-factor proposals (Livesley, Jang, & Vernon, 1998; Widiger & Simonsen, 2005). Moreover, a multigroup confirmatory factor analysis showed that this model was highly invariant and thus generalizable across two large clinical (n = 1,029) and general population (n = 659) samples.     

The effect of personality pathology on treatment outcome for Axis I disorders in dysfunctional clergy

The relationship between Narcissistic, Compulsive, Dependent, and Antisocial personality traits, as measured by the MCMI-III, and the clinical presentation and the treatment outcome for Axis I disorders, as measured by the MMPI-II was investigated. The subjects were 86 Roman Catholic priests and nuns who participated in 6 to 8 months of residential treatment. Pretreatment evaluation of the patients included the MCMI-III and the MMPI-2. Clinical presentation of Axis I disorders was measured by pretreatment scores on MMPI scales 2 (Depression), 7 (Psychasthenia), content scale DEP (Depression), and content scale ANX (Anxiety). Treatment outcome was measured by posttreatment MMPI-2 scores on these four variables. The results of this study suggest that the level of personality traits a patient possesses can significantly impact the clinical presentation of an Axis I disorder. Although the 48 patients with MCMI-III base rate scores above 74 had significantly higher pretreatment MMPI-2 scores than the patients with lower MCMI-III scores, both groups obtained posttreatment MMPI scores well within normal limits. The intensive individual and group therapy, extended length of stay, and emphasis on community living that the residential program provides may account for these results.     

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.     

DSM-5 personality traits and DSM-IV personality disorders

Two issues pertinent to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) proposal for personality pathology, the recovery of DSM-IV personality disorders (PDs) by proposed DSM-5 traits and the validity of the proposed DSM-5 hybrid model, which incorporates both personality pathology symptoms and maladaptive traits, were evaluated in a large undergraduate sample (N = 808). Proposed DSM-5 traits as assessed with the Personality Inventory for DSM-5 explained a substantial proportion of variance in DSM-IV PDs as assessed with the Personality Diagnostic Questionnaire-4+, and trait indicators of the 6 proposed DSM-5 PDs were mostly specific to those disorders with some exceptions. Regression analyses support the DSM-5 hybrid model in that pathological traits, and an indicator of general personality pathology severity provided incremental information about PDs. Findings are discussed in the context of broader issues around the proposed DSM-5 model of personality disorders.     

The relation of neediness and Axis II pathology

Neediness, as a maladaptive form of interpersonal dependency, has been implicated in a range of psychopathology, most commonly mood and personality disorders. In light of the literature's sparse and inconsistent findings, Bornstein, Hilsenroth, Padawer, and Fowler (2000) have called for a systematic evaluation of dependency's role across the spectrum of Axis II disorders. The current study of individuals without current or past Axis I diagnoses found that Neediness was significantly related to dimensions of dependent, borderline, and histrionic personality disorders. Implications for the assessment of interpersonal dependency and issues in need of further clarification are highlighted.     

Self-report methodology is insufficient for improving the assessment and classification of Axis II personality disorders

Current approaches to the assessment and classification of personality disorders (PDs) rely almost exclusively on self-report methodology. In this paper, we document the many difficulties with self-reports, including limitations in their accuracy, the confounding effect of mood state, and problems with the selection and retention of factors in factor analytic approaches to self-report questionnaires. We also discuss the role of implicit processes in self-reports, with special attention directed to the phenomenon of priming and its effect on outcome. To rectify these issues, we suggest a transtheoretical, multimethod, multimodal approach to personality pathology assessment and diagnosis, which utilizes the richness of prototypes and empirical findings on PD categories and pathologies.     

Modifications of Treatment Approaches for Axis I Disorders in Patients Who Also Have a Concurrent Axis II Disorder

Personality disorders have been an area of active interest in psychiatry for many years. Mental health professionals have suspected that these disorders retard the treatment of Axis I disorder and a comorbid personality (Axis II) disorder represents a special clinical challenge. This report draws from empirical literature in the field and the experience of the author to provide one possible theoretical framework to use in viewing these patients as well as practical suggestions to improve management of patients with these comorbid conditions.     

Moral nature of the DSM-IV Cluster B personality disorders

Moral considerations do not appear to play a large role in discussions of the DSM-IV personality disorders and debates about their empirical validity. Yet philosophical analysis reveals that the Cluster B personality disorders, in particular, may in fact be moral rather than clinical conditions. This finding has serious consequences for how they should be treated and by whom.     

Reliability of DSM-IV anxiety and mood disorders: implications for the classification of emotional disorders

The reliability of current and lifetime Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) anxiety and mood disorders was examined in 362 outpatients who underwent 2 independent administrations of the Anxiety Disorders Interview Schedule for DSM-IV: Lifetime version (ADIS-IV-L). Good to excellent reliability was obtained for the majority of DSM-IV categories. For many disorders, a common source of unreliability was disagreements on whether constituent symptoms were sufficient in number, severity, or duration to meet. DSM-IV diagnostic criteria. These analyses also highlighted potential boundary problems for some disorders (e.g., generalized anxiety disorder and major depressive disorder). Analyses of ADIS-IV-L clinical ratings (0-8 scales) indicated favorable interrater agreement for the dimensional features of DSM-IV anxiety and mood disorders. The findings are discussed in regard to their implications for the classification of emotional disorders.