Reliability and validity of the Coolidge Axis II Inventory: a new inventory for the assessment of personality disorders.

This group of studies describes the development of a 200 item, self-report, 4-point true-false inventory (Coolidge Axis II Inventory [CATI]) to assess personality disorders according to the criteria established in the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev. [DSM-III-R]; American Psychiatric Association, 1987). The 13 personality disorder scales of the CATI had a mean test-retest reliability of .90 and a median internal consistency (Cronbach's alpha) of .76. There was a 50% concordance rate with clinician's diagnosis for 24 personality disordered patients. The median concurrent validity (raw score sums) between the CATI and the Millon Clinical Multiaxial Inventory-II for the 13 personality disorder scales was .58. Preliminary studies also support the reliability and validity of Depression, Anxiety, and Brain Dysfunction scales.     

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.     

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.     

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.     

Behavioral assessment of personality disorders

This article examines the definition of personality disorders (PDs) from a functional analytical framework and discusses the potential utility of such a framework to account for behavioral tendencies associated with PD pathology. Also reviewed are specific behavioral assessment methods that can be employed in the assessment of PDs, and how information derived from these assessments may be linked to specific intervention strategies.     

Evidence-based assessment of personality disorders

The purpose of this article is to provide a foundation for the development of evidence-based guidelines for the assessment of personality disorders, focusing in particular on integrated assessment strategies. The general strategy recommended herein is to first administer a self-report inventory to alert oneself to the potential presence of particular maladaptive personality traits followed by a semistructured interview to verify their presence. This strategy is guided by the existing research that suggests particular strengths of self-report inventories and semistructured interviews relative to unstructured clinical interviews. However, the authors also consider research that suggests that further improvements to the existing instruments can be made. The authors emphasize, in particular, a consideration of age of onset, distortions in self-perception and presentation, gender bias, culture and ethnicity, and personality change.     

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.     

A structured interview for the assessment of the Five-Factor Model of personality: facet-level relations to the axis II personality disorders

The Structured Interview for the Five-Factor Model (SIFFM; Trull & Widiger, 1997) is an 120-item semistructured interview that assesses both adaptive and maladaptive features of the personality traits included in the five-factor model of personality, or "Big Five." In this article, we evaluate the ability of SIFFM scores to predict personality disorder symptomatology in a sample of 232 adults (46 outpatients and 186 nonclinical college students). Personality disorder symptoms were assessed using the Personality Diagnostic Questionnaire-Revised (PDQ-R; Hyler & Rider, 1987). Results indicated that many of the predicted associations between lower-order personality traits and personality disorders were supported. Further, many of these associations held even after controlling for comorbid personality disorder symptoms. These findings may help inform conceptualizations of the personality disorders, as well as etiological theories and treatment.     

The joint structure of DSM-IV Axis I and Axis II disorders

The Diagnostic and Statistical Manual (4th ed. [DSM-IV]; American Psychiatric Association, 1994) distinction between clinical disorders on Axis I and personality disorders on Axis II has become increasingly controversial. Although substantial comorbidity between axes has been demonstrated, the structure of the liability factors underlying these two groups of disorders is poorly understood. The aim of this study was to determine the latent factor structure of a broad set of common Axis I disorders and all Axis II personality disorders and thereby to identify clusters of disorders and account for comorbidity within and between axes. Data were collected in Norway, through a population-based interview study (N = 2,794 young adult twins). Axis I and Axis II disorders were assessed with the Composite International Diagnostic Interview (CIDI) and the Structured Interview for DSM-IV Personality (SIDP-IV), respectively. Exploratory and confirmatory factor analyses were used to investigate the underlying structure of 25 disorders. A four-factor model fit the data well, suggesting a distinction between clinical and personality disorders as well as a distinction between broad groups of internalizing and externalizing disorders. The location of some disorders was not consistent with the DSM-IV classification; antisocial personality disorder belonged primarily to the Axis I externalizing spectrum, dysthymia appeared as a personality disorder, and borderline personality disorder appeared in an interspectral position. The findings have implications for a meta-structure for the DSM.     

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

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

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.     

Outcome and epidemiological research on personality disorders: implications for classification

The construct of personality disorder has an overall definition that describes chronicity. However, the findings of outcome research indicate that while many patients stop meeting criteria for specific categories of disorder over time, they often continue to suffer from dysfunctional traits. One can also interpret epidemiological findings on personality disorders as overestimating disorders due to a failure to distinguish them from traits. Taken together, these findings point to the need for a revision of the classification of personality disorders that would separate enduring traits from reversible symptoms.     

Traits and trade-offs are insufficient for evolutionary personality psychology

Comments on the article by D. Nettle, who has clearly shown that evolutionary psychologists need to focus more attention on individual differences, not just species-typical universals. Such differences are not mere "noise," and evolutionary theory will gain by understanding how they are produced and maintained. However, by focusing on personality traits and the five-factor personality model, Nettle left unaddressed many of the most important aspects of human personality. An evolutionary psychology of personality must ultimately explain not just trait differences but also differences in personal goals, values, motives, identities, and life narratives--essential elements of human individuality and functionality. K. M. Sheldon et al suggest four reasons why traits and the five-factor personality model do not provide an optimal approach for explaining the evolution of personality: (a) As constructs, traits provide little purchase for explaining the causes of behavior; (b) trait concepts do not acknowledge or explain people's variations around their own baselines, variations that are likely crucial for adaptation; (c) traits do not explain or even describe true human uniqueness, i.e. the ways in which a person is different from everybody else; and (d) traits do not explain personality from the inside, by considering what people are trying to do in their lives. In raising these issues Sheldon et al are suggesting that the important question for evolutionary personality study is not why people fall at different points on a continuum regarding traits x, y, and z, but rather why each person is inevitably unique while still sharing the same evolved psychology.     

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 classification of personality disorders should be rooted in biology

As scientific classifications develop over time, they become based less on observations and more on mechanisms. Existing dimensional schema are limited by being overly broad and by being rooted in self-report rather than theory. Future models should be consistent with a scientific hierarchy, leading to a bottom-up classification of traits and disorders, linking molecular genetics, neurobiological markers, and temperamental variations.     

Continuity of axes I and II: toward a unified model of personality, personality disorders, and clinical disorders

In the current standard psychiatric nomenclature, the DSM-IV-TR (APA, 2000), mental disorders are divided into two groups: Clinical Disorders (CDs) and Personality Disorders (PDs), and CD and PD diagnoses are recorded on two separate axes (Axes I and II, respectively). This article considers evidence regarding putative bases for distinguishing between CDs and PDs, and finds that these constructs are more similar than distinct. Links between the domains may be better understood by focusing on how personality connects CDs and PDs. This perspective underlines the need to work toward a more unified model of personality, PDs, and CDs in research and in future editions of the DSM.     

Use of the TAT in the assessment of DSM-IV cluster B personality disorders

The Social Cognition and Object Relations Scale (SCORS), developed by Western, Lohr, Silk, Kerber, and Goodrich (1985), is a diagnostic instrument used to assess an array of psychological functioning by using clinical narratives such as the Thematic Apperception Test (TAT; Murray, 1943) stories. This study investigated the utility of the SCORS to differentiate between Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) antisocial personality disorder (ANPD), borderline personality disorder (BPD), narcissistic personality disorder (NPD), and Cluster C personality disorder (CPD). A sample of 58 patients was separated into four groups: ANPD (n = 9), BPD (n = 21; 18 with a primary BPD diagnosis and 3 with prominent borderline traits who met 4 of the 5 DSM-IV criteria necessary for a BPD diagnosis), NPD (n = 16; 8 with a primary NPD diagnosis and 8 with prominent narcissistic traits who met 4 of the 5 DSM-IV criteria necessary for a NPD diagnosis), and CPD (n = 12). These groups were then compared on the 8 SCORS variables by using 5 TAT cards (1, 2, 3BM, 4, and 13MF). Spearman-Brown correction for 2-way mixed effects model of reliability for the 8 SCORS variables ranged from .70 to .95. The results of categorical and dimensional analyses indicate that (a) SCORS variables can be used to differentiate ANPD, BPD, and NPD; (b) the BPD group scored significantly lower (greater maladjustment) than did the CPD group on certain variables; (c) the BPD group scored significantly lower (greater maladjustment) than did the NPD group on all 8 SCORS variables; (d) the ANPD group scored significantly lower than did the NPD group on certain variables; (e) certain variables were found to be empirically related to the total number of DSM-IV ANPD, BPD, and NPD criteria; and (f) certain variables were found to be empirically related to Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) Personality disorder scales. The results of this study are discussed in terms of clinical utility, conceptual, and theoretical implications.     

Treatment utilization and satisfaction: examining the contributions of Axis II psychopathology and the Five-Factor Model of personality

Numerous studies have demonstrated a link between personality disorders (PDs) and increased treatment utilization and decreased satisfaction. However, few studies have examined the link between general personality models, such as the Five-Factor Model (FFM), and these treatment variables. The current study examines the role of depression, anxiety, and functioning, PDs, and the FFM in accounting for psychiatric treatment utilization and satisfaction with care in two distinct clinical samples (n = 99 and 544, respectively). The results suggest that both maladaptive personality symptoms and general personality traits are predictive of these outcome variables. Importantly, the findings regarding treatment utilization replicate across samples and level of personality assessment (i.e., FFM and PDs). It is argued that both types of personality information should be included in the initial treatment planning and implementation stages.     

The personality disorders: A review and critique of contemporary assessment strategies

Despite the prevalence of personality disorders, only recently have they become the topic of extensive clinical research. Unfortunately, much of this research suffers from various assessment problems including poor interrater agreement, an overreliance on cross-sectional assessment, and inconsistencies across measures. The present review examines the strategies used to assess personality disorders. Three comprehensive tables are used to provide a quantitative review of existing studies. Although specific measures are examined, the focus remains on general strategies for assessment. Personality disorder assessment may be enhanced through the use of aggregation methods. Aggregating over raters can reduce the subjective biases inherent in any one person's perception. Aggregating data over time reduces the instability of personality assessment, while aggregating data across measures reduces the reliance on any one measure to assess personality disorders accurately. Thus, future research should be able to refine the strategies used to study personality disorders.     

Socio-demographic conditions, subjective somatic health, Axis I disorders and personality disorders in the common population: the relationship to quality of life

Quality of life (QOL) was studied in a population of 2,065 subjects in Norway. A broad concept of QOL was applied, including subjective well-being, self-realization, negative life events, and a number of interpersonal relationships. The assessment of QOL, based on interview, was related to a number of socio-demographic variables, subjectively experienced somatic health, the most common Axis I disorders, and all Axis II personality disorders (PDs). The results of multivariate analyses showed that being female and living with a partner in the outskirts of a city and having good physical health are important positive correlates of QOL. Controlling for all these variables, major depression, dysthymic disorder, and somatoform disorders were the Axis I disorders that have a negative statistical effect on global QOL. Specific anxiety disorders did not add to the effects. Among the PDs, avoidant, schizotypal, paranoid, and schizoid PD traits were the most important statistical negative determinants of QOL, followed by borderline, dependent, antisocial, and also self-defeating and narcissistic PDs, restricted to some specific sub-indexes of QOL. The study also showed that our results vary and are sometimes the opposite, depending on the sub-index of QOL examined. The study showed that it is necessary to apply a broad concept of QOL to disclose the real nature or the relationship between mental disorders and QOL. Furthermore, demographic variables, subjectively experienced somatic health, Axis I disorders, and PD traits appeared to be independently associated with QOL.