Using the structural analysis of social behavior (SASB) to differentiate young adults with borderline personality disorder features.

The present experiment investigated the ability of the Structural Analysis of Social Behavior (SASB) Intrex questionnaires to differentiate nonclinical samples of young adults with features of either borderline personality disorder (BPD), schizotypal personality disorder (SPD), or no personality disorder (no PD). A number of significant differences were demonstrated on the SASB Intrex questionnaires when comparisons were made between the BPD and no PD samples. These results are consistent with those reported in an earlier investigation of BPD using SASB in a clinical sample. Few differences were found between the SPD features sample and the other two samples. These results are not consistent with previous findings that have differentiated BPD and SPD in clinical samples. The results are discussed in terms of the possible implications for SASB to differentiate BPD, the use of nonclinical samples in personality disorder research, and dimensional models for conceptualizing personality disorders.     

Social anxiety in body dysmorphic disorder

Although clinical impressions suggest that patients with body dysmorphic disorder (BDD) experience distress in social situations, social anxiety in BDD has received little investigation. This study examined social anxiety in 81 patients with BDD and change in social anxiety with pharmacotherapy. Subjects completed the Social Avoidance and Distress Scale (SADS) and were assessed with measures of BDD symptomatology. Participants in a placebo-controlled fluoxetine trial completed measures at baseline and endpoint. The mean SADS score was 1.3 SD units higher than nonclinical sample means but consistent with other clinical sample means. Social anxiety was significantly correlated with BDD severity. Greater depressive symptoms as well as comorbid avoidant personality disorder, but not comorbid social phobia, were also associated with higher SADS scores. Social anxiety did not improve more with fluoxetine than placebo, yet it improved significantly more in fluoxetine responders than in nonresponders. Understanding social anxiety in BDD has implications for reducing rates of misdiagnosis and treatment dropout.     

Experimental manipulation of NEO-PI-R items.

Research assessing the relationship of the Five-factor model (FFM) of personality to personality disorder symptomatology has generally been consistent with theoretical expectations. Three exceptions, however, have been failures to confirm predicted associations of the NEO-Personality Inventory-Revised (NEO-PI-R) Conscientiousness scale with obsessive-compulsive personality disorder symptomatology, the NEO-PI-R Agreeableness scale with dependent symptomatology, and the NEO-PI-R Openness scale with schizotypal symptomatology. It was the hypothesis of this study that these findings might be due in part to a relative emphasis on adaptive rather than maladaptive variants of these domains of personality functioning within the NEO-PI-R. This hypothesis was tested by experimentally altering NEO-PI-R items to reverse their implications for maladaptiveness. The predicted correlations of the FFM were confirmed with the experimentally altered items in a sample of 86 adult psychiatric outpatients.     

Total number of MMPI-2 clinical scale elevations predicts premature termination after controlling for intake symptom severity and personality disorder diagnosis

Premature termination of therapy by patients is a common phenomenon that can be deleterious to treatment outcome for patients and also negatively affect therapists, treatment centers, and research programs. Therefore, a method of identifying patients at risk for premature termination could have widespread benefits. This study investigated whether patients’ MMPI-2 profiles, including clinical scale elevations and Negative Treatment Indicator (TRT) scores, could predict premature termination in an outpatient sample, controlling for personality disorder diagnosis and symptom severity at intake. Results indicated that while TRT scores were not incrementally predictive of premature termination, the total number of clinical scale elevations was significantly incrementally predictive of dropout. Clinical implications are discussed.     

Maladaptive personality functioning within the big five and the five-factor model

The five-factor model (FFM) of general personality functioning was derived originally from lexical studies of trait terms within the English language. Many studies have been conducted on the relationship of the FFM to personality disorder symptomatology but, as yet, no lexical study of the representation of maladaptive personality functioning within a language has been conducted. The current study identified the distribution of socially undesirable trait terms within each of the poles of the Big Five and compared this distribution to findings obtained with FFM personality disorder measures. The implications of the results for a FFM of personality disorders and for the FFM assessment of maladaptive personality functioning are discussed.     

Integrating normal and abnormal personality structure: a proposal for DSM-V

The personality disorders section of the American Psychiatric Association's fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is currently being developed. The purpose of the current paper is to encourage the authors of DSM-V to integrate normal and abnormal personality structure within a common, integrative model, and to suggest that the optimal choice for such an integration would be the five-factor model (FFM) of general personality structure. A proposal for the classification of personality disorder from the perspective of the FFM is provided. Discussed as well are implications and issues associated with an FFM of personality disorder, including validity, coverage, feasibility, clinical utility, and treatment implications.     

Generalized social phobia versus avoidant personality disorder: a commentary on three studies.

The findings of Herbert, Hope, and Bellack (1992), Holt, Heimberg, and Hope (1992), and Turner, Beidel, and Townsley (1992) are largely consistent. Avoidant personality disorder and generalized social phobia appear to be overlapping constructs that have only minor differences with respect to severity of dysfunction. This commentary addresses the implications of the findings with respect to the validity of the categorical distinction in the Diagnostic and Statistical Manual of Mental Disorders (rev. 3rd ed.; American Psychiatric Association, 1987) between avoidant personality and generalized social phobia, revisions of their respective diagnostic criteria, and their reclassification as either an anxiety or a personality disorder. Methodological and substantive suggestions for future research are also discussed.     

A dimensional model of personality disorder: incorporating DSM Cluster A characteristics

The authors articulate an expanded dimensional model of personality pathology to better account for symptoms of DSM-defined Cluster A personality disorders. Two hundred forty participants (98 first-degree relatives of probands with schizophrenia or schizoaffective disorder, 92 community control participants, and 50 first-degree relatives of probands with bipolar disorder) completed a dimensional personality pathology questionnaire, a measure of schizotypal characteristics, and Chapman measures of psychosis proneness. Scales from all questionnaires were subjected to an exploratory factor analysis with varimax rotation. A 5-factor structure of personality pathology emerged from the analyses, with Peculiarity forming an additional factor to the common 4-factor structure of personality pathology (consisting of Introversion, Emotional Dysregulation, Antagonism, and Compulsivity). These results support a 5-factor dimensional model of personality pathology that better accounts for phenomena encompassed by the Cluster A personality disorders in DSM-IV-TR (4th ed., text revised; American Psychiatric Association, 2000). This study has implications for the consideration of a dimensional model of personality disorder in DSM-V by offering a more comprehensive structural model that builds on previous work in this area.     

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.     

Influence of co-morbid generalized anxiety disorder, panic disorder and personality disorders on the outcome of cognitive behavioural treatment of obsessive-compulsive disorder

This study examined co-morbid generalized anxiety disorder and/or panic disorder and personality disorders as predictors of treatment outcomes in adult outpatients with obsessive-compulsive disorder. The patients received exposure with response prevention (ERP) treatment with the addition of either elements of cognitive therapy (ERP+CT) or relaxation training (ERP+REL). It was hypothesized that the addition of cognitive interventions would yield better treatment outcomes for patients with co-morbid generalized anxiety disorder and/or panic disorder. It was also hypothesized that patients with any personality disorder would show less treatment gains in both conditions. Using intention-to-treat criteria, patients with generalized anxiety disorder and/or panic disorder co-morbidity showed less treatment gains at post-treatment across both treatment conditions. This group showed significantly more treatment gains in the ERP+CT condition at the post-treatment and the 12-month follow-up assessments compared with patients in the ERP+REL condition. However, this was not significant when comparing treatment completers. Patients with a co-morbid Cluster A or B personality disorder showed significantly less treatment gains in both treatment conditions at the 12-month follow-up assessment. Among treatment completers, patients with a Cluster C personality disorder showed significantly better outcomes at the post-treatment assessment in the ERP+REL treatment condition. These results, clinical implications, and the importance of further investigations are discussed.     

Sadistic personality disorder in sex offenders: relationship to antisocial personality disorder and sexual sadism.

To investigate the relationship of sadistic personality disorder (SPD), as defined in the appendix of DSM-III-R, to other personality disorders and to sexual sadism, 70 sex offenders (27 child molesters, 33 rapists, and 10 murderers) were assessed by the International Personality Disorder Examination. In 19 subjects (27.2%) from the total sample, SPD was diagnosed. The highest overlap appeared with borderline personality disorder (31.6%) and antisocial personality disorder (42.1%). However, in four cases SPD was the only personality disorder diagnosed. Factor analysis of the antisocial and sadistic criteria resulted in four major factors--one factor with high loadings on the sadistic criteria and the violent criteria of antisocial personality disorder, two factors with different forms of adult and juvenile aggression, and a fourth factor with high loadings on the antisocial criteria covering exploitative behavior. The results do not support SPD as a discrete disorder. Nevertheless, SPD may be seen as an important subdimension of antisocial personality disorder, distinct from more exploitative forms of antisocial behavior with less violence. Of those patients with SPD, 42.1% also had a DSM-III-R diagnosis of sexual sadism, which may be the most dangerous configuration.     

Dangerous and severe personality disorders: a new personality concept from the United Kingdom

In 1998, we in England were shocked by the apparently motiveless murders of a mother and two of her children when they were traveling home from school in a rural area. Subsequently a patient with personality disorder, being monitored by the forensic psychiatric services, was convicted of their murders. The government was determined to prevent this type of offense from recurring and in 1999 introduced a new concept, dangerous and severe personality disorder (DSPD). This subsequently became a treatment and assessment program for individuals who satisfy three requirements: (1) have a severe disorder of personality, (2) present a significant risk of causing serious physical or psychological harm from which the victim would find it difficult or impossible to recover, and (3) the risk of offending should be functionally linked to the personality disorder. The implications of this program are discussed with regard to international systems of classification and service provision. We also attempt to place DSPD in the wider context of psychiatric participation in the management of personality disordered offenders.     

Distress tolerance as a predictor of early treatment dropout in a residential substance abuse treatment facility

A large percentage of individuals who enter residential substance abuse treatment drop out before completing treatment. Given that early treatment dropout places individuals at an increased risk for relapse, identifying the mechanisms underlying treatment dropout would have several important theoretical and clinical implications. In the current study, the authors examined levels of psychological and physical distress tolerance as a predictor of early treatment dropout in a residential substance abuse treatment facility. In a sample of 122 individuals entering a residential substance abuse treatment facility, level of psychological distress tolerance was predictive of early treatment dropout above and beyond relevant self-report variables. There was no relationship between physical distress tolerance and early treatment dropout. Implications for future studies and treatment development or modification are discussed.     

Brief report--associations of personality disorder with early separation anxiety in patients with adult separation anxiety disorder

A recent study has suggested a link between early separation anxiety and personality disorder. It is possible that this relationship is mediated or confounded by the presence of adult separation anxiety disorder (ASAD). In a clinic study of 397 anxiety patients, we found that ASAD patients with heightened early separation anxiety had higher rates of any Cluster C personality disorder compared to ASAD patients without elevated early separation anxiety, and higher rates of any Cluster B or C personality disorder compared to anxiety patients with low early separation anxiety and no ASAD. Although cross-sectional in design, the study supports a direct link between early separation anxiety and some adult personality disorders, irrespective of the type of adult anxiety disorder present, including ASAD.     

Relation Between Childhood Maltreatment and Severe Intrafamilial Male‐Perpetrated Physical Violence in Chinese Community: The Mediating Role of Borderline and Antisocial Personality Disorder Features

This study investigates the role of borderline personality disorder (BPD) and antisocial personality disorder (ASPD) features as mediators of the effects of childhood maltreatment on severe intrafamilial physical violence amongst Chinese male perpetrators. A cross‐sectional survey and face‐to‐face interview were conducted to examine childhood maltreatment, personality disorder features, impulsivity, aggression, and severe intrafamilial physical violence in a community sample of 206 abusive men in China. The results suggest that ASPD or BPD features mediate between childhood maltreatment and intimate partner violence perpetration in Chinese abusive men. These findings may yield clinical and forensic implications for assessing the psychopathology of abusive men, and may steer the intervention of intimate partner violence. Aggr. Behav. 38:64‐76, 2012. © 2011 Wiley Periodicals, Inc.     

Interviews of female patients with borderline personality disorder who dropped out of group psychotherapy

Premature termination from group psychotherapy continues to be a serious problem in the treatment of patients with borderline personality disorder (BPD). Qualitative research is regarded as an important means to shed light upon the complex dynamics leading to dropout. We conducted an interview study with patients having a diagnosis of BPD (n = 8) who dropped out from long-term group psychotherapy as a continuation therapy following intensive day treatment. The group therapists for these patients were interviewed as well (n = 12). The findings suggest the operation of many processes that contribute to dropout. Most significant appeared to be experiences of separation and loss of the day hospital that were not worked through and a failure of the group to regulate and contain the patients' affects. To integrate patients at risk of premature termination it seems necessary to pay attention to the strong negative emotions that they experience in the group. A higher treatment intensity than weekly group sessions may help to promote more beneficial group processes.     

Influence of Co‐Morbid Generalized Anxiety Disorder,Panic Disorder and Personality Disorders on the Outcome of Cognitive Behavioural Treatment of Obsessive‐Compulsive Disorder

This study examined co‐morbid generalized anxiety disorder and/or panic disorder and personality disorders as predictors of treatment outcomes in adult outpatients with obsessive‐compulsive disorder. The patients received exposure with response prevention (ERP) treatment with the addition of either elements of cognitive therapy (ERP+CT) or relaxation training (ERP+REL). It was hypothesized that the addition of cognitive interventions would yield better treatment outcomes for patients with co‐morbid generalized anxiety disorder and/or panic disorder. It was also hypothesized that patients with any personality disorder would show less treatment gains in both conditions. Using intention‐to‐treat criteria, patients with generalized anxiety disorder and/or panic disorder co‐morbidity showed less treatment gains at post‐treatment across both treatment conditions. This group showed significantly more treatment gains in the ERP+CT condition at the post‐treatment and the 12‐month follow‐up assessments compared with patients in the ERP+REL condition. However, this was not significant when comparing treatment completers. Patients with a co‐morbid Cluster A or B personality disorder showed significantly less treatment gains in both treatment conditions at the 12‐month follow‐up assessment. Among treatment completers, patients with a Cluster C personality disorder showed significantly better outcomes at the post‐treatment assessment in the ERP+REL treatment condition. These results, clinical implications, and the importance of further investigations are discussed.     

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.     

CIC, CLPS, and MSAD

The purpose of this article is to provide a commentary on the reports of the findings from the longitudinal Children in the Community (CIC) study by Cohen, Crawford, Johnson, and Kasen (this issue), Collaborative Longitudinal Personality Disorders Study (CLPS) by Skodol et al. (this issue), and McLean Study of Adult Development (MSAD) by Zanarini, Frankenburg, Hennen, Reich, and Silk (this issue). This article focuses in particular on the implications of their longitudinal findings with regard to a fundamental component of personality disorder: temporal stability. Also discussed are their findings with regard to an integration of general personality structure with personality disorder.     

Stability and Change in Personality Disorder

ABSTRACT— The standard view of personality disorder is that it is a maladaptive expression of personality traits, which are relatively stable and unchanging. Thus, personality disorder has been considered to have its roots in childhood and adolescence, to persist in adulthood, and to be difficult to change. However, recent research has challenged this view, revealing that personality continues to change, albeit more slowly, well into adulthood, and that the maladaptive manifestations of personality disorder are much less stable than previously believed. These research findings are described, and factors that influence stability and change in personality disorder are discussed. The emerging view of personality disorder has important implications for diagnosis, assessment, and treatment of personality pathology.