DSM-IV axis II comorbidity with borderline personality disorder in monolingual Hispanic psychiatric outpatients

The authors examined the comorbidity of DSM-IV borderline personality disorder (BPD) with other personality disorders (PD) in a series of adult monolingual (Spanish only) Hispanic psychiatric outpatients with substance use disorders. One hundred outpatients (69 men and 31 women) were assessed with the Spanish version of the Diagnostic Interview for DSM-IV Personality Disorders. PD co-occurrence in the group of patients with BPD (N = 34) was statistically compared with that in the group without BPD (N = 66). Bonferroni-corrected chi-square analysis showed significant diagnostic comorbidity with BPD for antisocial, avoidant, and depressive PD. However, analyses conducted separately by gender showed no significant comorbidity of any PD with BPD in women and significant comorbidity with antisocial, avoidant, and depressive PD in men. These results suggest that in monolingual Hispanic psychiatric outpatients with substance use disorders, gender may play a role in the nature of BPD comorbidity. The BPD diagnosis may represent a broader range of psychopathology in Hispanic men than women.     

Validity of the Structured Clinical Interview for DSM-IV Among Veterans Seeking Treatment for Substance Use Disorders

This paper examines the validity of the Structured Clinic Interview for DSM-IV (SCID) I and II in a sample of Veterans seeking treatment for substance use disorders (SUDs). Participants (N?=?183) initially receiving residential or outpatient treatment for SUDs completed the SCID I and II. More than one-third of participants met criteria for an Axis I disorder, and almost one-half met criteria for an Axis II disorder. Concurrent, discriminant, and predictive validity were examined for diagnoses of SUDs and antisocial personality disorder (APD), as well as symptoms of depression, anxiety, and thought disorder. Results generally provided strong support for the concurrent, discriminant, and predictive validity of the SCID I diagnoses of alcohol use disorders (AUDs) and strong support for the concurrent and discriminant validity of drug use disorders (DUDs). There was mixed support for the concurrent validity of APD. Predictive validity for DUDs or APD was not supported.     

Gender differences in borderline personality disorder: findings from the Collaborative Longitudinal Personality Disorders Study

A majority of the literature on borderline personality disorder (BPD) focuses on its occurrence in women or does not specifically assess for gender differences in clinical presentations. Some studies report that men with BPD may be more likely to be diagnosed with substance use disorders, as well as paranoid, passive-aggressive, narcissistic, sadistic, and antisocial personality disorders (PDs). Additionally, women with BPD appear to be more likely to report histories of adult physical and sexual abuse and to meet diagnostic criteria for post-traumatic stress disorder (PTSD) and eating disorders. The purpose of the present study was to further examine gender differences in BPD. Using baseline data from the Collaborative Longitudinal Personality Disorders Study (CLPS), men and women who met criteria for BPD were compared on current axis I and II disorders, BPD diagnostic criteria, childhood trauma histories, psychosocial functioning, temperament, and personality traits. Men with BPD were more likely to present with substance use disorders, and with schizotypal, narcissistic, and antisocial PDs, while women with BPD were more likely to present with PTSD, eating disorders, and the BPD criterion of identity disturbance. Generally speaking, women and men with BPD displayed more similarities than differences in clinical presentations. The differences that did emerge are consistent with those found in epidemiological studies of psychopathology and therefore do not appear unique to BPD. Additionally, many gender differences traditionally found in epidemiological samples did not emerge in BPD subjects. For example, no difference was found in rates of major depressive disorder, a condition that is more prevalent in females. Thus, BPD pathology may be a prevailing characterization that can attenuate usual gender-based distinctions.     

Ethnicity and four personality disorders

The current study examined the relationship between ethnicity and DSM-IV personality disorders. The distribution of four personality disorders--borderline (BPD), schizotypal (STPD), avoidant (AVPD), and obsessive-compulsive (OCPD)--along with their criteria sets, were compared across three ethnic groups (Caucasians, African Americans, and Hispanics) using both a clinician-administered diagnostic interview and a self-report instrument. Participants were 554 patients drawn from the Collaborative Longitudinal Personality Disorders Study (CLPS) who comprised these three ethnic groups and met personality disorder criteria based on reliably administered semistructured interviews. Chi-square analyses revealed disproportionately higher rates of BPD in Hispanic than in Caucasian and African American participants and higher rates of STPD among African Americans when compared to Caucasians. Self-report data reflected similar patterns. The findings suggest that in treatment-seeking samples, Caucasians, Hispanics, and African Americans may present with different patterns of personality pathology. The factors contributing to these differences warrant further investigation.     

An investigation of the validity of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition avoidant personality disorder construct as a prototype category and the psychometric properties of the diagnostic criteria

This study investigated several aspects of the validity of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition avoidant personality disorder (APD) construct, with emphasis on the psychometric properties of the diagnostic criteria and the prototype nature of the construct. A sample of 1,058 patients from the Norwegian Network of Psychotherapeutic Day Hospitals was examined by means of exploratory factor analysis, correlation, and diagnostic efficiency statistics, chi(2) analysis, and frequency distribution. The results indicated that APD is a 1-dimensional construct with good internal consistency. The criteria had acceptable diagnostic efficiency; criterion 3 performed poorest. Number of APD criteria showed no distinct threshold between No-APD and patients with APD. Sixty-two different combinations of any 4 APD criteria occurred. It can be concluded that the prototype model fitted the data well and that the APD diagnostic criteria perform well in the current classification system. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition hierarchy of criteria was not supported.     

Exploratory factor analysis of borderline personality disorder criteria in hospitalized adolescents

OBJECTIVE: The authors examined the factor structure of borderline personality disorder (BPD) in hospitalized adolescents and also sought to add to the theoretical and clinical understanding of any homogeneous components by determining whether they may be related to specific forms of Axis I pathology. METHOD: Subjects were 123 adolescent inpatients, who were reliably assessed with structured diagnostic interviews for Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition Axes I and II disorders. Exploratory factor analysis identified BPD components, and logistic regression analyses tested whether these components were predictive of specific Axis I disorders. RESULTS: Factor analysis revealed a 4-factor solution that accounted for 67.0% of the variance. Factor 1 ("suicidal threats or gestures" and "emptiness or boredom") predicted depressive disorders and alcohol use disorders. Factor 2 ("affective instability," "uncontrolled anger," and "identity disturbance") predicted anxiety disorders and oppositional defiant disorder. Factor 3 ("unstable relationships" and "abandonment fears") predicted only anxiety disorders. Factor 4 ("impulsiveness" and "identity disturbance") predicted conduct disorder and substance use disorders. CONCLUSIONS: Exploratory factor analysis of BPD criteria in adolescent inpatients revealed 4 BPD factors that appear to differ from those reported for similar studies of adults. The factors represent components of self-negation, irritability, poorly modulated relationships, and impulsivity--each of which is associated with characteristic Axis I pathology. These findings shed light on the nature of BPD in adolescents and may also have implications for treatment.     

Longitudinal diagnostic efficiency of DSM-IV criteria for borderline personality disorder: a 2-year prospective study.

OBJECTIVE: To examine the longitudinal diagnostic efficiency of the DSM-IV criteria for borderline personality disorder (BPD). METHODS: At baseline, we used semistructured diagnostic interviews to determine criteria and diagnoses; blinded assessments were performed 24 months later with 550 participants. Diagnostic efficiency indices (specifically, conditional probabilities, total predictive power, and kappa) were calculated for each criterion determined at baseline, with the independent BPD diagnosis at follow-up used as the standard. RESULTS: Longitudinal diagnostic efficiencies for the BPD criteria varied, with the criteria of suicidality or self-injury and unstable relationships demonstrating the most predictive utility. CONCLUSIONS: BPD criteria differ in their predictive utility for the diagnosis of BPD when considered longitudinally. These findings have implications both for clinicians who are considering diagnoses and for researchers concerned with forthcoming revisions of our nosological system.     

Operationalisierte Diagnostik der Borderline-Persönlichkeitsstörung Eine Befragung von Psychiatern und Psychologen bezüglich ihrer Syndromvorstellungen

Despite the diagnostic criteria of the ICD-10 and DSM-IV, the term borderline has been used in a non-specific way for a long time. For our investigation we constructed a questionnaire, which contained the ICD-10 diagnostic criteria for the borderline personality disorder (BPD), plus the criteria for the other personality disorders and for the schizotype disorder. The two additional criteria for the BPD used by the DSM-IV were added. 800 psychiatrists and psychologists were asked to mark all criteria, which they thought were typical for the BPD. By using the operational diagnostic approach for ICD-10 and DSM-IV a disorder was diagnosed from each of the 162 received questionnaires based on the marked criteria. 92.0% of the questionnaires contained marked criteria for the diagnosis of the BPD by ICD-10 and 96.3% by DSM-IV. In addition each questionnaire contained up to eight other diagnosis. This is a sign for the difficulty to separate the BPD from other personality disorders or the schizotype disorder by using operationalized criteria. Looking at the lack of specificity of the operational diagnostic systems for personality disorders, e.g. for the BPD which has been discussed by many authors for years, modification of the diagnostic systems should be considered.     

Borderline personality and eating disorders

Borderline personality disorder (BPD) is an Axis II disorder that is characterized by an intact fa?ade, longstanding self-regulation difficulties and self-harm behavior, and unstable interpersonal relationships and mood. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV; American Psychiatric Association, 1994), the prevalence of BPD in the general population is around 2%. The symptoms of the disorder appear to be influenced by gender. Despite defined diagnostic criteria, BPD tends to have polymorphic clinical presentations with both multiple psychological and somatic symptoms. The etiology of BPD appears to be related to genetic predisposition, early developmental trauma, and biparental failure, although other contributory factors may be involved. We discuss, through the use of several models, the possible relationships between BPD and eating disorders.     

Psychiatric and substance use disorders in South Florida: racial/ethnic and gender contrasts in a young adult cohort.

BACKGROUND: Prevalence rates of psychiatric and substance use disorders among young adults in South Florida are presented. Unique aspects of the study include the large sample size, its ethnic diversity, and the fact that a substantial proportion of Hispanic participants were foreign born. METHODS: This study builds on a previous cohort study of students who entered middle school in 1990. A random subsample of this representative cohort (N = 1803) was interviewed between 1998 and 2000 when most were between 19 and 21 years of age. Disorders were assessed through computer-assisted personal interviews utilizing the DSM-IV version of the Michigan Composite International Diagnostic Interview. RESULTS: More than 60% of the sample met lifetime criteria for 1 or more study disorders, and 38% did so within the preceding year. Childhood conduct and major depressive and alcohol abuse disorders were the most prevalent. Although rates of affective and anxiety disorders in females were double that in males, this gender difference disappeared when attention-deficit/hyperactivity disorder, conduct disorders, and antisocial personality disorders were also considered (46.6% vs 45.7% for females vs males, respectively). Substantially lower rates were observed among African Americans for depressive disorders and substance abuse and dependence. Among Hispanics, rates tend to be lower among the foreign-born in comparison with their US-born counterparts, particularly for the substance disorders. CONCLUSIONS: The documented presence of psychiatric and substance disorders in middle and high school populations emphasizes the importance of prevention efforts in school settings. Research on the origins of ethnic and nativity differences is called for.     

Factor structure and diagnostic efficiency of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for avoidant personality disorder in Hispanic men and women with substance use disorders

Objective

This study examined the internal consistency, factor structure, and diagnostic efficiency of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), criteria for avoidant personality disorder (AVPD) and the extent to which these metrics may be affected by sex.

Method

Subjects were 130 monolingual Hispanic adults (90 men, 40 women) who had been admitted to a specialty clinic that provides psychiatric and substance abuse services to Spanish-speaking patients. All were reliably assessed with the Spanish-Language Version of the Diagnostic Interview for DSM-IV Personality Disorders. The AVPD diagnosis was determined by the best-estimate method. After evaluating internal consistency of the AVPD criterion set, an exploratory factor analysis was performed using principal components extraction. Afterward, diagnostic efficiency indices were calculated for all AVPD criteria. Subsequent analyses examined men and women separately.

Results

For the overall group, internal consistency of AVPD criteria was good. Exploratory factor analysis revealed a 1-factor solution (accounting for 70% of the variance), supporting the unidimensionality of the AVPD criterion set. The best inclusion criterion was “reluctance to take risks,” whereas “interpersonally inhibited” was the best exclusion criterion and the best predictor overall. When men and women were examined separately, similar results were obtained for both internal consistency and factor structure, with slight variations noted between sexes in the patterning of diagnostic efficiency indices.

Conclusions

These psychometric findings, which were similar for men and women, support the construct validity of the DSM-IV criteria for AVPD and may also have implications for the treatment of this particular clinical population.     

Convergent and discriminant validity of DSM-IV axis II personality disorder criteria in adult outpatients with binge eating disorder

The study objective was to evaluate the within-category cohesiveness and between-category overlap of DSM-IV axis II personality disorders (PDs) in outpatients with binge eating disorder (BED). Seventy adult outpatients with BED were reliably administered the Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV). Within-category interrelatedness of the criteria was evaluated by Cronbach's alpha and mean intercriterion correlations (MICs). Between-category criterion overlap was evaluated by examining intercategory mean intercriterion correlations between all pairs of PDs (ICMICs). Cronbach's alpha was .64 to .93 (mean, .77), the MIC was .17 to .52 (mean, .34), and the ICMIC was .11 to .39 (mean, .28). Our findings indicate that in outpatients with BED, the DSM-IV PD criteria sets have convergent validity (acceptable alpha value and MIC). Some degree of discriminant validity also exists: criteria for most DSM-IV PDs correlate better with each other (MIC) than with criteria for other PDs (ICMIC).     

Diagnostic efficiency and hierarchical functioning of the DSM-IV borderline personality disorder criteria

This study presents information regarding the diagnostic efficiency and hierarchical functioning of the newly revised DSM-IV borderline personality disorder (BPD) criteria. Past research using the DSM-III-R version of BPD showed that the individual BPD criteria differ greatly in their diagnostic utility and that in some clinical situations, fewer than five of eight criteria could efficiently make the diagnosis. Two groups of inpatients, a BPD group (N = 33) and a non-BPD group (N = 43), were rated on the DSM-IV BPD criteria. Acceptable interrater reliability (Kappa estimates) was obtained for the presence or absence of the nine individual BPD criteria. Diagnostic efficiency statistics, sensitivity, specificity, false positive and false negative rates, positive predictive power, negative predictive power, overall classification rate and Kappa with the clinical diagnosis were obtained for all nine BPD criteria. The diagnostic efficiency data indicated that BPD criteria 1 (abandonment) and 2 (unstable relationships) functioned best in our inpatient sample, whereas criterion 9 (stress-related paranoia) performed the poorest. A stepwise logistic regression showed that the combination of BPD criteria 2, 1, 6 (unstable affect), and 3 (identity) (presented in their order of entry into the regression equation) provided the best prediction of group membership (BPD or non-BPD). The results suggest that a further refinement of both the BPD criteria set and the diagnostic decision rules may be needed.     

Internal consistency, intercriterion overlap and diagnostic efficiency of criteria sets for DSM-IV schizotypal, borderline, avoidant and obsessive-compulsive personality disorders.

OBJECTIVE: To evaluate performance characteristics of DSM-IV Personality Disorders (PDs) criteria. METHOD: Six hundred and sixty-eight adults recruited for the Collaborative Longitudinal Personality Disorders Study (CLPS) were assessed with diagnostic interviews. RESULTS: Within-category inter-relatedness was evaluated by Cronbach's alpha and median intercriterion correlations (MIC). Cronbach's alpha ranged from 0.47 to 0.87 (median=0.71); seven of the 10 PDs had alphas greater than 0.70. Between-category criterion overlap was evaluated by "inter-category" intercriterion correlations between all PD pairs (ICMIC). ICMIC values (median=0.08) were lower than MIC values (median=0.23). Diagnostic efficiency statistics (sensitivity, specificity, positive predictive power and negative predictive power were calculated for schizotypal, borderline, avoidant and obsessive-compulsive PDs. CONCLUSION: DSM-IV PD criteria sets have some convergent validity and discriminant validity: criteria for individual PDs correlate better with each other than with criteria for other PDs. Diagnostic efficiency statistics provide guidance regarding usefulness of criteria for inclusion or exclusion.     

Co-occurrence of mood and personality disorders: a report from the Collaborative Longitudinal Personality Disorders Study (CLPS)

The purpose of this study was to examine the relationship of subtypes and particular clinical features of mood disorders to co-occurrence with specific personality disorders. Five hundred and seventy-one subjects recruited for the Collaborative Longitudinal Personality Disorders Study (CLPS) were assessed with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and the Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV). Percent co-occurrence rates for current and lifetime mood disorders with personality disorders were calculated. Logistic regression analyses examined the effects of clinical characteristics of depressive disorders (e.g., age at onset, recurrence, symptom severity, double depression, and atypical features) on personality disorder co-occurrence. In comparison with other DSM-IV personality disorders, avoidant, borderline, and dependent personality disorders (PDs) were most specifically associated with mood disorders, particularly depressive disorders. Severity and recurrence of major depressive disorder and comorbid dysthymic disorder predicted co-occurrence with borderline and to a lesser extent research criteria depressive personality disorders. The results are consistent with the view that a mood disorder with an insidious onset and recurrence, chronicity, and progression in severity leads to a personality disorder diagnosis in young adults.     

Prevalence of DSM-IV disorders in Chinese adolescents and the effects of an impairment criterion

Purpose

To provide preliminary prevalence estimates of common DSM-IV (Diagnostic and Statistical Manual of Mental Disorders—4th Edition) disorders in a sample of Hong Kong Chinese adolescents.

Methods

541 Chinese adolescents were recruited from Grades 7, 8 and 9 of 28 mainstream high schools in Hong Kong (mean age=13.8 years; SD=1.2). The adolescents and their parents were separately administered the Youth and Parent versions of DISC-IV (Diagnostic Interview Schedule for Children-Version 4), respectively.

Results

Based upon both symptom and impairment criteria, as required by DSM-IV, the overall prevalence estimate of DSM-IV disorders in our sample of Chinese adolescents was 16.4%. Estimates for such individual disorders/diagnostic groupings as anxiety disorders, depressive disorders, attention deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder (CD), and substance use disorders were 6.9, 1.3, 3.9, 6.8, 1.7, and 1.1%, respectively. These rates were largely compatible with those reported in previous studies with perhaps lower rates of generalized anxiety disorder (GAD), depressive disorders, CD, and substance use disorders, but a higher rate of ODD. The rate of ADHD was somewhat higher, but this might reflect the current DSM-IV diagnostic practice. The rate of anxiety disorders was not as high as predicted from some previous questionnaire surveys. The application of an impairment criterion had discernible impacts on prevalence estimates, greater on anxiety and substance use disorders, but smaller on depressive and disruptive behavior disorders. There was a lack of gender difference in rates of ODD and CD.

Discussion and conclusion

While the findings reported here are broadly compatible with those of other studies, there may be cross-cultural differences in rates of some individual disorders, e.g., GAD, depressive disorders, ODD, CD, and substance use disorders, as well as in gender difference regarding rates of ODD and CD. However, exact comparison between studies is confounded by methodological differences in sample characteristics, measures, and case definition. Standardization of methodology in epidemiological surveys should allow more precise identification of any within- or between-culture variations in prevalence estimation.     

Psychiatric diagnoses of treatment-seeking cocaine abusers

In a sample of 298 cocaine abusers seeking inpatient (n = 149) or outpatient (n = 149) treatment, rates of psychiatric disorders were determined by means of the Schedule for Affective Disorders and Research Diagnostic Criteria. Overall, 55.7% met current and 73.5% met lifetime criteria for a psychiatric disorder other than a substance use disorder. In common with previous reports from clinical samples of cocaine abusers, these overall rates were largely accounted for by major depression, minor bipolar conditions (eg, hypomania, cyclothymic personality), anxiety disorders, antisocial personality, and history of childhood attention deficit disorder. Affective disorders and alcoholism usually followed the onset of drug abuse, while anxiety disorders, antisocial personality, and attention deficit disorder typically preceded drug abuse.     

Social phobia and avoidant personality disorder: one spectrum disorder?

General population data was used to examine if empirically derived subtypes of social phobia with and without avoidant personality disorder (APD) could be differentiated on self-report measures of anxiety severity, level of global functioning and the number of fulfilled diagnostic criteria for other personality disorders. DSM-IV diagnoses of social phobia, APD and indices of other personality disorders were determined by means of a postal survey. The presence of APD was associated with compromised functional status and a higher frequency of fulfilled diagnostic criteria for additional personality disorders. However, APD did not modify the effect of social phobia subtypes on anxiety severity, level of global functioning or number of personality disorder indices. The presence of comorbid APD in social phobics seems to predict a global functioning decrement independent of anxiety severity. The results imply that social phobia and APD may represent different points on a severity continuum rather than easily defined discreet categories suggesting that social phobia and APD may represent a spectrum of anxiety symptoms related to social anxiety.     

Comorbid personality disorders and substance use disorders of mentally ill homicide offenders: a structured clinical study on dual and triple diagnoses

Comorbid substance use disorders (SUDs) increase the risk of homicide by persons with major mental disorders (MMDs). However, there are no published data from clinical interviews or lifetime objective documents on the prevalence of lifetime personality disorder (PD) or SUD among a comprehensive sample of mentally ill homicide offenders. Therefore, a nationally representative sample of men with MMD (n = 90) who had committed or attempted homicide was assessed using the research version of the Structured Clinical Interview for DSM-IV Axis I and Axis II Disorders. Lifetime documents, records, and questionnaires from persons who knew the subjects since childhood were used. Seventy-eight percent of the mentally ill homicide offenders were diagnosed with schizophrenia, 17 percent with schizoaffective disorder, and 5 percent with other psychosis. A lifetime SUD was detected in 74 percent and alcohol use disorder in 72 percent. PD accounted for 51 percent, in 47 percent as antisocial personality disorder (APD). All subjects diagnosed with PD had SUD. Only 25 percent of the subjects had neither SUD nor PD. Among persons with dual diagnoses (MMD and SUD), about two-thirds had PD or APD. These results indicated that there were two-thirds major diagnostic categories of psychotic homicide offenders: about one-half had triple diagnosis (APD + SUD + MMD), one-quarter had "pure" dual diagnosis (SUD + MMD), and one-quarter had "pure" MMD. The fourth possible category, "APD + MMD but no SUD," was not found. The prevention of severe violence by persons with MMD necessitates effective treatments for those with dual diagnosis who also have a history of APD.     

Polythetic diagnostic approach to the borderline personality disorder. the valency of the single criterion in the concept of professional therapists

The present study addresses the question whether the polythetic approach of ICD-10 and DSM-IV is useful in clinical practice for the diagnosis 'Borderline' personality disorder (BPD). A questionnaire containing all individual criteria for the 9 personality disorders and the schizotypal disorder used by the ICD-10, completed by the DSM-IV criteria for the BPD not covered by the ICD-10, was developed. Eight hundred therapists were asked to mark the importance of every single criterion for forming the diagnosis or for ruling out BPD. Our data analysis of the received questionnaires performed a rankscore based on an altered calculation of the mean value. The criteria which described the patients' instability in relationship and mood, and identity disturbances were seen as the most important features for the diagnosis of BPD. The criterion of cognitive disturbances, newly introduced in DSM-IV, was not felt to be a major clinical feature. In conclusion, our study reflects the results of other authors in the sense that a single criterion cannot be considered pathognomonic for BPD, but has greater importance and a higher priority in establishing the diagnosis BPD. This should be taken into account to reconsider the polythetic concept in favor of a hierarchical approach with core criteria.