DSM-III personality disorder diagnoses in a nonpatient sample. Demographic correlates and comorbidity

Seven hundred ninety-seven first-degree relatives of normal controls and patients with a variety of psychiatric disorders were interviewed with the Diagnostic Interview Schedule and the Structured Interview for DSM-III Personality Disorders. Slightly more than one sixth of the sample received a personality disorder (PD) diagnosis, and of those with a PD, almost one fourth had more than one. The most prevalent diagnoses were mixed, passive-aggressive, antisocial, histrionic, and schizotypal PD. The demographic correlates and frequency of Axis I disorders in individuals with each specific PD were examined, and all but histrionic and passive-aggressive PDs had distinctive profiles.     

The effects of changing axis II diagnostic criteria.

This study examined whether changes in diagnostic criteria from the DSM-III to the DSM-III for personality disorders (PDs) had the intended effects. Seventy-two subjects at the University of Iowa from three research studies and one clinical sample were administered two structured interviews (the Structured Interview for DSM-III Personality [SIDP] and the revised SIDP [SIDP-R]) to assess DSM-III and DSM-III-R criteria. Major changes in rates of diagnoses were observed between the DSM-III and DSM-III-R criteria with kappas for agreement ranging between -.025 and .571. As expected, the switch from monothetic to polythetic definitions had an effect on which patients were assigned a given diagnosis. However, not all of the other revisions associated with the DSM-III-R had the intended effects. For instance, the frequency of the diagnosis of schizoid PD did not increase, nor did the overlap between borderline and histrionic PDs decrease. In addition, there was an unintended increase in the rate of paranoid PD. An analysis of individual criteria showed how small, apparently minor changes in the wording of criteria can sometimes have major effects on which patients received a diagnosis of PD.     

Diagnosing personality disorders in recent-onset schizophrenia

The present study aimed to determine the prevalence of personality disorders (PDs) and personality disorder traits in 40 recent-onset schizophrenic patients, to establish the degree of concordance between the Structured Interview for DSM-III Personality Disorders (SIDP) and the Million Multiaxial Clinical Inventory (MCMI-I), and to examine the interrater reliabilities for the diagnosis of SIDP disorders and traits. During their recovery phase, patients underwent the SIDP and completed the MCMI-I, a self-report inventory. Results showed that 57% of all patients had PDs according to the SIDP. The most common PDs were antisocial, borderline, and schizotypal, whereas the most common according to the MCMI-I were dependent, narcissistic, and avoidant. Both instruments indicated that multiple PD diagnoses were common. Paranoid and schizotypal traits were found to be ubiquitous across instruments. The level of agreements between the two instruments was poor on diagnostic assignment but better when trait scores were considered.     

Diagnosing personality disorders in psychiatric inpatients

This study investigated assumptions made by DSM-III and DSM-III-R regarding Axis I-Axis II associations and sex differences for the 11 personality disorders (PD). A total of 112 patients formed 4 Axis I diagnostic groups: recent-onset schizophrenia (n = 35); recent-onset mania (n = 26); unipolar affective disorder (n = 30); and a mixed diagnostic group (n = 21). The prevalence of PD was determined using the Structured Interview for DSM-III Personality Disorders (SIDP). Schizophrenia was associated with antisocial PD and schizotypal PD; manic disorder was associated with histrionic PD; and unipolar affective disorder was associated with borderline, dependent and avoidant PD. Some of these results were consistent with DSM-III/DSM-III-R postulates. However, there was little support for the DSM-III/DSM-III-R statements on sex differences in the prevalence of PD, except for antisocial PD. The implications of the results for DSM-III/DSM-III-R assumptions are discussed.     

DSM-III personality disorder dimensions

Dimensional scores were computed for the 11 DSM-III personality disorders (PDs) in 797 relatives of psychiatric patients and never ill control subjects interviewed with the Structured Interview for DSM-III Personality Disorders. The distribution of scores for all 11 PD dimensions was skewed to the right. A principal components analysis with varimax rotation produced three factors that closely corresponded to DSM-III's suggested clustering of the PDs into eccentric, dramatic, and anxious types. Men scored significantly higher on the paranoid, schizoid, compulsive, antisocial, and narcissistic dimensions, whereas women had significantly higher histrionic, dependent, and avoidant scores. Age was negatively correlated with most of the PD dimensions, and the correlations were strongest with the four PDs in cluster 2 (histrionic, antisocial, narcissistic, and borderline). Each of the eight axis I disorders examined was associated with increased axis II pathology.     

Empirical determination of thresholds for case identification: Validation of the Personality Diagnostic Questionnaire-Revised

The Personality Diagnostic Questionnaire-Revised (PDQ-R) was sent to first-degree relatives of major psychotic patients for identification of DSM-III-R personality disorders (PDs). Responses to the PDQ-R were interpreted both literally and empirically, and compared with the Structured Interview for DSM-III PDs (SIDP) as the standard. For literal interpretation, symptoms reported were counted directly for case identification using fixed DSM-III-R thresholds. The empirical approach adjusted the threshold for case identification to maximize concordance with the SIDP. Comparison of the two methods showed that using empirically determined thresholds in some scales gives better concordance with the SIDP. For the dependent and histrionic PD scales, the improvements were statistically significant. The area under the receiver operating characteristic (ROC) curve was computed for each PDQ-R scale to summarize its discriminatory capability across all thresholds. Areas under the ROC curve indicated that the schizoid, schizotypal, borderline, dependent, passive-aggressive, and histrionic PD scales in the PDQ-R have better discriminatory qualities than other PDQ-R scales.     

Premorbid personality disorders in schizophrenia

Premorbid personality disorders (PD) were studied retrospectively in 40 schizophrenic patients by interviewing the parents and patients who were reliable with the SCID-II. 85% of the patients had premorbid PDs. The most frequent premorbid PDs were: avoidant PD (32. 5%), schizoid PD (27.5%), paranoid PD (20%), dependent PD (20%) and schizotypal PD (12.5%). In most of the patients, two or more PDs could be diagnosed simultaneously (47.5%), comorbilidity of the premorbid PDs in schizophrenia being the most common one. The most frequent combination was avoidant-schizoid-schizotypal PD.     

Correlates of DSM-III personality disorder in obsessive-compulsive disorder

Forty-three patients with primary obsessive-compulsive disorder (OCD) completed the Personality Diagnostic Questionnaire (PDQ), a self-rating scale designed to assess axis II personality disorders (PD) from DSM-III. Results showed that 53% of the patients received at least one PD diagnosis. The most frequent diagnoses were avoidant (30%), histrionic (26%), dependent (19%), and schizotypal (16%). Consideration of the personality traits irrespective of diagnostic category showed that in addition to avoidant and dependent personality characteristics, the sample had strong passive aggressive and compulsive tendencies and substantial histrionic, paranoid, and schizotypal traits. Patients exhibiting a greater number of personality traits were also significantly more symptomatic. However, anxiety, phobic, and obsessive-compulsive symptoms were not selected as unique predictors of any personality variables in the regression analyses. Rather, the most important correlate of PD in these patients consisted of dysphoric mood as assessed by the Beck Depression Inventory (BDI) and, to a lesser degree, younger age or shorter duration of illness. These findings do not support a specific link between OCD and PD in general and compulsive PD in particular.     

Standardized assessment of personality disorders in obsessive-compulsive disorder

We assessed 96 patients with obsessive-compulsive disorder for DSM-III personality disorder diagnoses with a standardized interview instrument (Structured Interview for the DSM-III Personality Disorders). Fifty patients (52%) met criteria for at least one personality disorder, with mixed, dependent, and histrionic personality disorders most frequently diagnosed. Compulsive personality disorder was diagnosed in only 6 patients (6%), 5 of whom had had onset of obsessive-compulsive symptoms before the age of 10 years, indicating that DSM-III compulsive personality disorder is not invariably a premorbid condition for the development of obsessive-compulsive disorder. Schizotypal personality disorder, at 5%, was found to be less common than in past samples, reflecting differences in either assessment methods or sampling.     

DSM-III-R narcissistic personality disorder evaluated by patients'' and informants'' self-report questionnaires: Relationships with other personality disorders and a sense of entitlement as an indicator of narcissism

Modified versions of the revised Personality Diagnostic Questionnaire (PDQ-R) for DSM-III-R personality disorders (PDs) were completed by 60 patients and their informants. Patients' ratings gave a mean number of 4.5 PDs per subject and narcissistic (NAR) PD in 42%. Informants' ratings gave NAR PD in 38%. For patients and informants, NAR PD scores (i.e., the number of positive NAR PD criteria for each subject) were significantly correlated with histrionic (HIS) and borderline (BOR) PD scores and with scores of some PDs outside DSM-III-R's "cluster B." Also, there were significant correlations between patients' and informants' NAR PD scores and between NAR PD scores and total number of positive criteria (i.e., for all 13 PDs) for patients and informants. For patients' ratings, there were significant associations between NAR PD and HIS, BOR, and passive-aggressive (PAG) PDs and, for informants' ratings, between NAR and HIS PDs. There was no significant association between patients' and informants' diagnoses of NAR PD. Grandiosity, the most characteristic feature of narcissism, is related to NAR PD criteria 3 through 6. The patients' evaluation of criterion 6 (i.e., "Has a sense of entitlement ...") shows satisfactory item-total correlation and endorsement frequency, together with "fair to good" reliability when patients' and informants' ratings are compared (kappa = 0.62). The identification of a sense of entitlement by the patient may be a relatively reliable and valid indicator of narcissism.     

Clinical correlates and significance of separation anxiety in patients with bipolar disorder

OBJECTIVES: To evaluate frequency and severity of separation anxiety (SA) symptoms, as well as frequency of DSM-IV diagnosis of childhood separation anxiety disorder (CSAD) and adult separation anxiety disorder (ASAD), in a group of patients with bipolar disorder (BD) when compared with patients with panic disorder (PD) or major depression (MDD) and to a control group of healthy individuals (HC). METHODS: Outpatients with, respectively, bipolar I disorder (BD), PD, MDD and a group of individuals with no psychiatric diagnoses (HC) were assessed for diagnosis by the SCID-I and for SA by the Structured Clinical Interview for Separation Anxiety Symptoms (SCI-SAS), the Separation Anxiety Symptoms Inventory (SASI) and the Adult Separation Anxiety Checklist (ASA-CL). RESULTS: Thirty-one patients with BD without comorbid PD (BD-PD), 22 with BD with comorbid PD (BD + PD), 24 with PD, 20 with MDD and 15 HC were included in the analyses. As to childhood SA, the BD-PD group had higher scores than PD group and HC. The BD + PD group had higher scores than the PD group, MDD group and HC. As to adulthood SA, the BD-PD group had higher scores than HC on both SCI-SAS and Adult Separation Anxiety Questionnaire (ASA-27). The BD + PD had higher scores on both scales than BD-PD, PD group, MDD group and HC. The PD group and MDD group had higher scores than HC on the ASA-27. Adult SA symptoms were significantly associated with an earlier age at onset of BD. CONCLUSIONS: This is the first study, to our knowledge, exploring the frequency and severity of SA symptoms during childhood and adulthood in a sample of bipolar patients in comparison to subjects with other anxiety and mood disorders. Our data appear to be preliminary grounds for investigating further the possibility that SA may deserve greater recognition in adults with BD.     

Personality disorders in somatization disorder patients: a controlled study in Spain

OBJECTIVE: The aim of this paper is to assess personality disorder (PD) comorbidity in somatization disorder (SD) patients compared with psychiatric controls in a Spanish sample. METHODS: This is a case-control study. Selection of 70 consecutive SD patients was made, and an age-, sex-, and ethnic-group-matched control group of 70 mood and/or anxiety disorder patients recruited in psychiatric outpatient clinics was selected. PDs were measured using the International Personality Disorder Examination, and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I morbidity was measured by means of the Standardized Polyvalent Psychiatric Interview. RESULTS: PD comorbidity in SD patients was 62.9%, compared to 28.2% in controls [odds ratio (OR)=3.7; 95% confidence interval (95% CI)=1.8-7.6]. The highest ORs of PD in SD patients, compared with controls, were for paranoid (OR=9.2; 95% CI=1.9-43), obsessive-compulsive (OR=6.2; 95% CI=1.2-53.6), and histrionic (OR=3.6; 95% CI=0.9-13.9) PDs. CONCLUSIONS: This is a controlled study with the largest sample of SD patients. The prevalence of PD comorbidity is similar to that of a previously published controlled study but is different from those of the most frequent PD subtypes.     

Frequency of comorbid personality disorders in bipolar and unipolar affective disorders

One expression of the complex relationship between personality and affective disorder is the comorbidity of personality disorders (PDs) with affective disorders. In a sample of 117 patients with unipolar and 60 with bipolar affective disorders, we assessed DSM-III-R PDs with the Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II) and compared them with personality factors as obtained by the five-factor model (FFM-NEO Five-Factor Inventory). Fifty-one percent of the unipolar and 38% of the bipolar disorders fulfilled criteria for a comorbid PD. The three most frequent PDs were obsessive-compulsive PD, borderline PD, and narcissistic (bipolar) or avoidant (unipolar) PD. Cluster C PDs and especially avoidant PD occurred significantly more frequently in unipolar than in bipolar patients, while narcissistic PD occurred significantly more often in bipolar than in unipolar patients. The FFM results supported the validity of our PD diagnoses. In a logistic regression analysis, higher depression score at the time of the SCID-II interview and shorter duration of the illness were weakly related to a higher frequency of PDs. Our results indicate that PDs are frequent in affective disorders and that there are subtle differences between unipolar and bipolar patients concerning such comorbid disorders.     

Personality disorders in a clinical sample of Cannabis dependent young adults

INTRODUCTION: Cannabis addiction with comorbid personality disorders (PDs) is associated with a heavier individual burden of disease. Most previous studies focussed on singular disorders like borderline or antisocial PD, there is little data available on the full range of PD. Even less is known about the prevalence of PD with cannabis addiction in inpatient settings. The aim of this study is to investigate the frequency of PD and their relevance in treatment of young adult Cannabis-dependent inpatients. METHODS: 99 adolescents and young adults diagnosed with Cannabis dependence according to DSM I, were investigated during their detoxification treatment in an addiction treatment ward. Personality disorders were assessed using the SCID II questionnaire. RESULTS: The intensity of personality disorder traits was high in this inpatient sample. The probands showed a higher burden of disease from PDs other than the antisocial and Borderline PDs previously reported. Almost 90% of the subjects received the diagnosis of an antisocial PD, more than half had a paranoid and more than a third suffers from a Borderline PD. More than 35% of the sample had more than three PDs. There were no consistent relationships between PDs and concurrent consumption of other drugs, severity of drug addiction or delinquency. CONCLUSION: There is evidence of PDs in almost all inpatient Cannabis-dependent adolescents and young adults. Diagnosis and treatment of these subjects has to provide not only addiction-specific approaches but also strategies to improve dysfunctional behaviour caused by personality disorder characteristics.     

The NIMH-DIS in the assessment of DSM-III schizophrenic disorder

The National Institute of Mental Health Diagnostic Interview Schedule (NIMH-DIS) was administered by trained lay interviewers to a sample of 82 outpatients with clinical diagnoses of DSM-III schizophrenic disorder. Of these subjects, 77 percent were also diagnosed as suffering from DSM-III schizophrenic disorder according to the structured interview (NIMH-DIS) administered by a lay interviewer. The DIS interviews were scrutinized to find the reasons for their discrepancy with the clinical diagnoses. A majority of the DIS-negative schizophrenic subjects acknowledged significant psychopathology in the DIS and missed only one of the six DSM-III criteria items for schizophrenia. Test-retest results showed consistency in the subjects' reporting of lifetime schizophrenic symptoms.     

Comparison between personality disorder diagnoses in DSM-III and DSM-III-R: reliability, diagnostic overlap, predictive validity

97 nonpsychotic consecutive day patients were diagnosed by the axis 1 and 2 in the DSM-III and DSM-III-R system, and their treatment response during their stay was measured by the Health Sickness Rating Scale. The interrater reliability was equally good for both diagnostic systems. On axis 1, there were only minor differences between DSM-III and DSM-III-R. On axis 2, the frequency of schizotypal disorder was reduced by 40% and the frequency of histrionic disorder by two-thirds. The number of schizoid disorders increased from zero to five. Of the DSM-III schizotypals who lost this diagnosis in DSM-III-R (n = 8), 4 got a new diagnosis of schizoid personality and 4 maintained their borderline diagnoses. In DSM-III-R there was a sharper demarcation between patients with severe and nonsevere personality disorder with regard to treatment outcome, indicating an increased validity of these categories. There was also a sharper demarcation between borderline versus histrionic and schizotypal, and between schizotypal and schizoid diagnoses.     

Prevalence of DSM-III personality disorders in the community

Summary A community sample of adults with a standardized DSM-III, Axis II self-report instrument yielded an age adjusted community prevalence of 11.1% of DSM-111 personality disorders. When those with personality disorders (PDs) (n = 26) were compared to those without personality traits (n = 467) the PD group had less education 14.9 (3.0) years vs 16.5 (3.3) years,p = 0.02) and a greater percentage with difficulty with alcohol (19% vs 0.6%,p = 0.0001). Of those married, more 1 PDs reported marital difficulties (29% vs 3.5%,p = 0.002). There was a trend for the PD group to have longer unemployment (p = 0.07).     

A twin study of personality disorders

No twin study has previously investigated the whole range of personality disorders (PDs) recorded by interviews. Based on twin and patient registries, 92 monozygotic (MZ) and 129 dizygotic (DZ) twin pairs were interviewed with the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II). Observed prevalence rates from a normal population study of more than 2,000 individuals were used in combination with data from the present study to generate statistics assumed to be valid for a normal twin population, and these statistics were used for structural equation modeling. The best-fitting models had a heritability of .60 for PDs generally, .37 for the eccentric (A) cluster, .60 for the emotional (B) cluster, and .62 for the fearful (C) cluster. Among the specific PDs, the heritability appeared to be .79 for narcissistic, .78 for obsessive-compulsive, .69 for borderline, .67 for histrionic, .61 for schizotypal, .57 for dependent, .54 for self-defeating, .29 for schizoid, .28 for paranoid, and .28 for avoidant PDs. The best-fitting models never included shared-in-families environmental effects. However, a model with only shared familial and unique environmental effects could not be ruled out for dependent PD. Shared familial environmental effects may also influence the development of any PD and borderline PD. Passive-aggressive PD did not seem to be affected by genes or family environment at all. The low occurrence of antisocial PD in the twin sample precluded any model for this disorder. PDs seem to be more strongly influenced by genetic effects than almost any axis I disorder, and more than most broad personality dimensions. However, we observed a large variation in heritability among the different PDs, probably partly because of a moderate sample size and low prevalence of the specific disorders.     

Co-occurrence of 12-month alcohol and drug use disorders and personality disorders in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions

BACKGROUND: Very little information is available on the co-occurrence of different personality disorders (PDs) and alcohol and drug use disorders in the US population. OBJECTIVE: To present national data on sex differences in the co-occurrence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) alcohol and drug use disorders and 7 of the 10 DSM-IV PDs. DESIGN: Face-to-face interviews conducted in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (N = 43 093). SETTING: The United States and the District of Columbia, including Alaska and Hawaii. PARTICIPANTS: Household and group-quarters residents, aged 18 years and older. RESULTS: Among individuals with a current alcohol use disorder, 28.6% (95% confidence interval [CI], 26.7-30.6) had at least 1 PD, whereas 47.7% (95% CI, 43.9-51.6) of those with a current drug use disorder had at least 1 PD. Further, 16.4% (95% CI, 15.1-17.6) of individuals with at least 1 PD had a current alcohol use disorder and 6.5% (95% CI, 5.7-7.3) had a current drug use disorder. Associations between PDs and alcohol and drug use disorders were overwhelmingly positive and significant (P <.05). Overall, alcohol use disorders were most strongly related to antisocial (odds ratio [OR], 4.8; 95% CI, 4.1-5.6), histrionic (OR, 4.7; 95% CI, 3.8-5.8), and dependent (OR, 3.0; 95% CI, 1.9-4.8) PDs. Drug use disorders also were more highly associated with antisocial (OR, 11.8; 95% CI, 9.7-14.3), histrionic (OR, 8.0; 95% CI, 6.0-10.7), and dependent (OR, 11.6; 95% CI, 7.1-19.1) PDs. Associations between obsessive-compulsive, histrionic, schizoid, and antisocial PDs and specific alcohol and drug use disorders were significantly stronger (P <.04) among women than men, whereas the association between dependent PD and drug dependence was significantly greater (P <.04) among men than women. CONCLUSIONS: The co-occurrence of PDs with alcohol and drug use disorders is pervasive in the US population. Results highlight the need for further research on the underlying structure of these disorders and the treatment implications of these disorders when comorbid.