Gender bias in diagnostic criteria for personality disorders: an item response theory analysis

The authors examined gender bias in the diagnostic criteria for Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision; American Psychiatric Association, 2000) personality disorders. Participants (N=599) were selected from 2 large, nonclinical samples on the basis of information from self-report questionnaires and peer nominations that suggested the presence of personality pathology. All were interviewed with the Structured Interview for DSM-IV Personality (B. Pfohl, N. Blum, & M. Zimmerman, 1997). Using item response theory methods, the authors compared data from 315 men and 284 women, searching for evidence of differential item functioning in the diagnostic features of 10 personality disorder categories. Results indicated significant but moderate measurement bias pertaining to gender for 6 specific criteria. In other words, men and women with equivalent levels of pathology endorsed the items at different rates. For 1 paranoid personality disorder criterion and 3 antisocial criteria, men were more likely to endorse the biased items. For 2 schizoid personality disorder criteria, women were more likely to endorse the biased items.     

An application of item response theory analysis to alcohol, cannabis, and cocaine criteria in DSM-IV

Item response theory (IRT) is supplanting classical test theory as the basis for measures development. This study demonstrated the utility of IRT for evaluating DSM-IV diagnostic criteria. Data on alcohol, cannabis, and cocaine symptoms from 372 adult clinical participants interviewed with the Composite International Diagnostic Interview--Expanded Substance Abuse Module (CIDI-SAM) were analyzed with Mplus (B. Muthen & L. Muthen, 1998) and MULTILOG (D. Thissen, 1991) software. Tolerance and legal problems criteria were dropped because of poor fit with a unidimensional model. Item response curves, test information curves, and testing of variously constrained models suggested that DSM-IV criteria in the CIDI-SAM discriminate between only impaired and less impaired cases and may not be useful to scale case severity. IRT can be used to study the construct validity of DSM-IV diagnoses and to identify diagnostic criteria with poor performance.     

Evidence-based treatments for adolescents with cannabis use disorders in the Spanish Public Health System

The goal of the present study is to describe the implementation of two Evidence-based treatments (EBT) for adolescent Cannabis Use Disorders (CUD) in the Spanish Public Health System, and its main clinical outcomes. Adolescent Community Reinforcement Approach (A-CRA) and Contingency Management (CM) were chosen as the most efficacious treatment programs for this population. A total of 26 adolescent cannabis users entered the study (91.7% male; age = 16.50) at two outpatient clinical facilities in Spain. A quasi-experimental design was utilized, with one group receiving A-CRA only and the other A-CRA + CM. Implementation of both EBTs resulted feasible, with positive clinical outcomes. Results indicated that A-CRA has positive retention (81.3%) and abstinence rates (68.8%). Results for the group receiving A-CRA + CM were not significantly better than A-CRA in retention (100%) or abstinence (75.5%), although sample is too small to establish firm conclusions. Cannabis-related problems and depressive symptomatology also decreased during treatment. Several limitations prevent us from determining the clinical efficacy of A-CRA in this study. The process of translating EBT's to clinical contexts presented with many difficulties that need to be overcome. Recommendations are made for further attempts to implement EBTs in these contexts.     

Prospective analysis of comorbidity: tobacco and alcohol use disorders

Alcohol use disorders (AUD) and tobacco use disorders (TD) frequently co-occur. The authors examined AUD-TD comorbidity over time using a state-trait (ST) model. The ST model represents variance in AUD/TD as a traitlike factor that spans measurement occasion and identifies distinct sources of variance in AUD-TD comorbidity. The ST model was evaluated on 450 young adults (baseline age = 18.5 years; 51% with family history of alcoholism) assessed 5 times over 7 years. The ST model demonstrated superior fit over a first-order autoregressive model. The tendency to diagnose with AUD and TD was partially explained by family history of alcoholism; this relationship was mediated by childhood stressors, alcohol expectancies, and behavioral undercontrol. Results supported a common third-variable influence (vs. directional) model of comorbidity. The ST model is an important conceptual and methodological approach to the prospective study of comorbidity in general.     

Item response theory analysis of intimate-partner violence in a community sample

The Revised Conflict Tactics Scale (CTS2; Straus, Hamby, Boney-McCoy, & Sugarman, 1996) is a widely used measure of physical, psychological, and sexual aggression as well as injury and negotiation between partners. In this study, we analyzed male-to-female and female-to-male physical aggression using data from 453 community couples. We used item-response theory (IRT) to assess the range and precision of physical aggression severity in the past year, as evaluated by the CTS2. Our analyses support a single dimension of physical aggression with quantitative, rather than qualitative, differentiation between minor and severe physical aggression items. Surprisingly, test information curves revealed that male perpetration and victimization items provided as much or more information as their counterpart female victimization and perpetration items over the same range of aggression severity. Finally, the data suggests that CTS2 items best assessed moderate-to-severe levels of physical aggression in the previous 12 months. However, virtually no information was assessed by male or female reports of perpetration or victimization items below or around the mean of aggression (i.e., theta; θ = 0). Suggestions for improved item coverage and implications for the assessment of aggression are discussed.     

Symptom dimensions in obsessive-compulsive disorder: implications for the DSM-V

In the absence of definitive etiological markers of vulnerability or a unitary profile of pathophysiology for obsessive-compulsive disorder (OCD), obsessive-compulsive (OC) symptom dimensions seem to offer a fruitful point of orientation. The complex clinical presentation of OCD can be summarized using a few consistent and temporally stable symptom dimensions. These can be understood as a spectrum of potentially overlapping features that are likely to be continuous with "normal" worries and extend beyond the traditional nosological boundaries of OCD. Although the understanding of the dimensional structure of obsessive-compulsive symptoms (OCS) is still imperfect, this quantitative approach to phenotypic traits has the potential to advance our understanding of OCD and may aid in the identification of more robust endophenotypes. Preliminary data suggest that these dimensional phenotypes may be useful in studies of the natural history, genetics, neurobiology, and treatment outcome of OCD. A dimensional approach is not mutually exclusive of other methods to parse the larger spectrum of disorders related to OCD. Thus far, age-of-onset of OCS and the individual's "tic-related" status seem to be particularly useful categorical distinctions. Finally, existing assessment methods are inadequate and new dimensional scales are needed to take full advantage of a dimensional approach in clinical and population-based studies.     

Interactive voice response for relapse prevention following cognitive-behavioral therapy for alcohol use disorders: a pilot study

Relapse after alcoholism treatment is high. Alcohol Therapeutic Interactive Voice Response (ATIVR) is an automated telephone program for posttreatment self-monitoring, skills practice, and feedback. This pilot study examined feasibility of ATIVR. Participants (n = 21; 57% male) had access to ATIVR for 90 days following outpatient group cognitive-behavioral therapy (CBT) to make daily reports of mood, confidence in sobriety, urges to use substances, and actual use. Reports of relapse or risk were followed with additional questions. Participants received personalized therapist feedback based on responses, and could access recorded CBT skill reviews. Pre-post assessments included: alcohol consumption (Timeline Follow-Back), self-efficacy (Situational Confidence Questionnaire), and perceived coping ability (Effectiveness of Coping Behaviors Inventory). Participants called on 59% of scheduled days and continued making calls for an average of 84 days. Following ATIVR, participants gave feedback that ATIVR was easy to use and increased self-awareness. Participants particularly liked the therapist feedback component. Abstinence rate increased significantly during ATIVR (p = .03), and both self-efficacy and coping significantly improved from pre-CBT to post-ATIVR (p < .01). Results indicate ATIVR is feasible and acceptable. Its efficacy should be evaluated in a randomized controlled trial.     

Children's use of landmarks: implications for modularity theory

Previous studies have shown that disoriented children use the geometric features of the environment to reorient, but the results have not consistently demonstrated whether children can combine such information with landmark information. Results indicating that they cannot suggest the existence of a geometric module for reorientation. However, results indicating that children can use geometric information in combination with landmark information challenge the modularity interpretation. An uncontrolled variable in the studies yielding conflicting results has been the size of the experimental space. In the present studies, which tested young children in spaces of two different sizes, the size of the space affected their ability to use available landmark information. In the small space, the children did not use the landmark to reorient, but in the large space they did. The ability of children to use landmarks in combination with geometric information raises important questions about the existence of an encapsulated geometric module.     

Item response theory and the measurement of clinical change

An instrument's sensitivity to detect individual-level change is an important consideration for both psychometric and clinical researchers. In this article, we develop a cognitive problems measure and evaluate its sensitivity to detect change from an item response theory (IRT) perspective. After illustrating assumption checking and model fit assessment, we detail 4 features of IRT modeling: (a) the scale information curve and its relation to the bandwidth of measurement precision, (b) the scale response curve and how it is used to link the latent trait metric with the raw score metric, (c) content-based versus norm-based score referencing, and (d) the level of measurement of the latent trait scale. We conclude that IRT offers an informative, alternative framework for understanding an instrument's psychometric properties and recommend that IRT analyses be considered prior to investigations of change, growth, or the effectiveness of clinical interventions.     

Normative warrant in diagnostic criteria: the case of DSM-IV-TR personality disorders

This article focuses on the kinds of evaluative judgments made when applying DSM-IV-TR diagnostic criteria within the diagnostic interview between clinician and patient. The authors name these kinds of value judgments in diagnosis "normative warrant" because they involve one or more justifications (warrants) for standard-bearing (normative) elements involved in applying diagnostic criteria to actual patients. Seven types of normative warrant judgments are described (Type 1, Semantic-Phenomenal Matching; Type 2, Solicitation Choice; Type 3, Sociocultural Context; Type 4, Performance-Context Matching; Type 5, Deviance Threshold; Type 6, Threshold Characterization; Type 7, Disvalue characterization) and the typology is illustrated by applying it to various DSM-IV-TR personality disorder criteria. A research and clinical understanding of normative warrant may well contribute to the refinement of criteria sets as well as the refinement of the clinical use of criteria sets.     

Externalizing psychopathology in adulthood: a dimensional-spectrum conceptualization and its implications for DSM-V

Mental disorders involving antisocial behavior and substance use are genetically linked and vary continuously. The authors present a review and integrative conceptualization of these observations in terms of a dimensional and hierarchically organized externalizing spectrum. As a foundation for this conceptualization, the authors introduce a quantitative, model-based approach to comparing categorical and continuous conceptions of psychopathology and apply this approach in an empirical study of patterns of comorbidity among externalizing disorders as defined in the Diagnostic and Statistical Manual of Mental Disorders. The authors present evidence that comorbidity among externalizing disorders is best modeled by an underlying normally distributed continuum of risk for multiple disorders within the externalizing spectrum. The authors conclude by discussing implications of the externalizing spectrum conceptualization for classification of disorders in the upcoming 5th edition of the Diagnostic and Statistical Manual of Mental Disorders.     

The severity and status of eating disorder NOS: implications for DSM-V

"Eating disorder NOS" is the most common eating disorder encountered in outpatient settings yet it has been neglected. The aim of this study was to describe the characteristics of eating disorder NOS, establish its severity, and determine whether its high relative prevalence might be due to the inclusion of cases closely resembling anorexia nervosa or bulimia nervosa. One hundred and seventy consecutive patients with an eating disorder were assessed using standardised instruments. Operational DSM-IV diagnoses were made and eating disorder NOS cases were compared with bulimia nervosa cases. Diagnostic criteria were then adjusted to determine the impact on the prevalence of eating disorder NOS. Cases of eating disorder NOS comprised 60.0% of the sample. These cases closely resembled the cases of bulimia nervosa in the nature, duration and severity of their psychopathology. Few could be reclassified as cases of anorexia nervosa or bulimia nervosa. The findings indicate that eating disorder NOS is common, severe and persistent. Most cases are "mixed" in character and not subthreshold forms of anorexia nervosa or bulimia nervosa. It is proposed that in DSM-V the clinical state (or states) currently embraced by the diagnosis eating disorder NOS be reclassified as one or more specific forms of eating disorder.     

Classification of depressive disorders in the DSM-V: proposal for a two-dimension system

The number of categories and specifiers for mood disorders has increased with each successive edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM). Many of these categories and specifiers can be viewed as an effort to map the various permutations of severity and chronicity that characterize the depressive disorders. However, this has resulted in a system that (a) is unnecessarily complex and unwieldy, (b) has created problems with artificial distinctions between categories and artifactual comorbidity, and (c) at the same time obscures what may be more fundamental distinctions. A potentially useful and more parsimonious approach to capturing much of the heterogeneity of depressive disorders is to classify the depressive disorders along 2 dimensions, 1 reflecting severity and the other, chronicity. Considerations in the development of these dimensions are discussed, and a set of examples is presented. Although further research and discussion are needed to determine the optimal form of these dimensions, the next edition of the DSM should consider replacing many of the existing categories and specifiers for depressive disorders with the simpler approach of classifying depressive disorders using the 2 dimensions of severity and chronicity.     

Rethinking the mood and anxiety disorders: a quantitative hierarchical model for DSM-V

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) groups disorders into diagnostic classes on the basis of the subjective criterion of "shared phenomenological features." There are now sufficient data to eliminate this rational system and replace it with an empirically based structure that reflects the actual similarities among disorders. The existing structural evidence establishes that the mood and anxiety disorders should be collapsed together into an overarching class of emotional disorders, which can be decomposed into 3 subclasses: the bipolar disorders (bipolar I, bipolar II, cyclothymia), the distress disorders (major depression, dysthymic disorder, generalized anxiety disorder, posttraumatic stress disorder), and the fear disorders (panic disorder, agoraphobia, social phobia, specific phobia). The optimal placement of other syndromes (e.g., obsessive-compulsive disorder) needs to be clarified in future research.     

Patterns of alcohol use among rural and small-town adolescents

Much research has indicated that age, gender, grade in school, religiosity, socioeconomic status, and involvement in extracurricular activities are all related to adolescent alcohol use. However, most of such research focuses on urban youth. The present study examines patterns of rural adolescent alcohol use and factors associated with such use. The Student Alcohol Inventory was administered to 650 students in grades 7-12 in a small, middle-Atlantic town and surrounding county. The survey contained sections addressing demographic data, attitudes regarding students' alcohol use, and their parents' use. Along with standard SES measures, items were included on unemployment and receipt of government assistance. The dependent variables included age at first drink, frequency of drinking, amount of drinking, and a composite heavy-drinking index. Eighty-three percent of the respondents indicated that they had drunk alcohol and 57% had had their first drink by age 12. Gender and grade in school were significant predictors of alcohol use for all four dependent variables. Time spent in social activities was significant in predicting all but age at first drink. Religiosity was a significant predictor for only one dependent variable--age at first drink. The SES measures were also weak predictors of drinking behavior. Policy implications and directions for future research are discussed.     

Adolescent alcohol use and suicide indicators among adolescents in Hawaii

Research on suicide has focused on gender, age, ethnicity, and psychiatric profiles. However, few studies have examined alcohol use and its relationship to suicide among Native Hawaiians and other Asian American/Pacific Islanders. This study analyzes data from the 1997 and 1999 Hawaii Youth Risk Behavior Survey to examine whether alcohol problems increase the risk for suicide indicators (as evidenced by responses to questions asking whether an individual has considered, planned, attempted, or required treatment for a suicide attempt). Drinking pattern was the best predictor for all suicide indicators. School and community-based programs can help to increase an adolescent's knowledge about the consequences of alcohol use and prevention of suicide.     

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.