Diagnosing personality disorders in the community. A comparison of self-report and interview measures

The rapidly expanding empirical study of personality disorders is the result of the publication of operational diagnostic criteria in DSM-III and the development of instruments to assess these criteria. Few researchers have examined the comparability of measures of personality disorders, and to our knowledge there are no studies of the factors associated with discordance between measures. In the present study, 697 relatives of psychiatric patients and healthy controls were interviewed with the Structured Interview for Personality Disorders (SIDP) and completed the Personality Disorders Questionnaire (PDQ). Significantly more individuals had a personality disorder according to the SIDP; however, multiple personality disorders were more frequently diagnosed on the PDQ. Schizotypal, compulsive, dependent, and borderline personality disorders were significantly more frequently diagnosed by the PDQ, whereas the SIDP more frequently diagnosed antisocial and passive-aggressive personality disorder. The corresponding dimensional scores of the two measures were all significantly correlated; however, the concordance for categorical diagnoses was poor. Discrepancies between the PDQ and the SIPD dimensional scores were significantly associated with current level of depressive symptoms and PDQ lie scale scores.     

Chance discovery of multiple personality disorder in a depressed patient by amobarbital interview

Although the diagnosis of multiple personality disorder (MPD) has been receiving renewed interest in the literature, it presents a number of clinical problems and challenges. A case study is reported in which this diagnosis was uncovered by chance during an amobarbital interview on a psychotically depressed young male patient. The patient had previously been only minimally responsive to pharmacotherapy for a major depressive episode with mood-congruent psychotic features. When the multiple personality disorder was diagnosed, treatment emphasis shifted toward psychotherapeutic modalities with marked clinical improvement. Several unique aspects of the case, including diagnostic methodology, results of serial dexamethasone suppression tests, and psychosomatic symptomatology, are discussed as well as the implications of this case within a larger clinical context.     

Concurrent and predictive validity of the personality disorder diagnosis in adolescent inpatients.

OBJECTIVE: The authors investigated the concurrent and predictive validity of the DSM-III-R diagnosis of personality disorder in adolescents by means of baseline and follow-up assessments of inpatients treated at the Yale Psychiatric Institute. METHOD: One hundred sixty-five hospitalized adolescents were reliably assessed by using a structured interview for personality disorder diagnoses as well as two measures of impairment and distress--the Global Assessment of Functioning Scale and the SCL-90-R. Two years after initial assessment, 101 subjects were independently reassessed with the same measures; their functioning was also assessed at this time. RESULTS: At baseline, adolescents with personality disorders were significantly more impaired than those without personality disorders. At follow-up, adolescents with a personality disorder diagnosis at baseline had used significantly more drugs and had required more inpatient treatment during the follow-up interval. Over time, the scores on the Global Assessment of Functioning Scale and SCL-90-R of adolescents diagnosed with a personality disorder at baseline became more similar to the scores of adolescents without a personality disorder. CONCLUSIONS: The diagnosis of personality disorder in adolescent inpatients has good concurrent validity; however, the predictive validity of the diagnosis is mixed.     

The validity of self-rated psychotic symptoms in depressed inpatients

BackgroundSelf-ratings of psychotic experiences might be biased by depressive symptoms.MethodData from a large naturalistic multicentre trial on depressed inpatients (n = 488) who were assessed on a biweekly basis until discharge were analyzed. Self-rated psychotic symptoms as assessed with the 90-Item Symptom Checklist (SCL-90) were correlated with the SCL-90 total score, the SCL-90 depression score, the Beck Depression Inventory (BDI), the Hamilton Depression Rating Scale 21 item (HAMD-21) total score, the Montgomery Åsberg Depression Rating Scale (MADRS) total score and the clinician-rated paranoid-hallucinatory score of the Association for Methodology and Documentation in Psychiatry (AMDP) scale.ResultsAt discharge the SCL-90 psychosis score correlated highest with the SCL-90 depression score (0.78, P < 0.001) and with the BDI total score (0.64, P < 0.001). Moderate correlations were found for the MADRS (0.34, P < 0.001), HAMD (0.37, P < 0.001) and AMDP depression score (0.33, P < 0.001). Only a weak correlation was found between the SCL-90 psychosis score and the AMDP paranoid-hallucinatory syndrome score (0.15, P < 0.001). Linear regression showed that change in self-rated psychotic symptoms over the treatment course was best explained by a change in the SCL-90 depression score (P < 0.001). The change in clinician-rated AMDP paranoid-hallucinatory score had lesser influence (P = 0.02).ConclusionsIn depressed patients self-rated psychotic symptoms correlate poorly with clinician-rated psychotic symptoms. Caution is warranted when interpreting results from epidemiological surveys using self-rated psychotic symptom questionnaires as indicators of psychotic symptoms. Depressive symptoms which are highly prevalent in the general population might influence such self-ratings.     

The prognostic validity of DSM-III axis IV in depressed inpatients

DSM-III suggests that axis IV should have prognostic value--that patients with higher scores will have a better outcome than patients with low ratings. The authors used axis IV to assign scores to 130 depressed inpatients and examined these scores in association with the patients' course during the index hospitalization and at 6-month prospective follow-up. Higher axis IV scores were associated with more depressive symptoms on hospital discharge, but they did not predict follow-up outcome. These results are consistent with other studies of the prognostic value of ratings of psychosocial stress and indicate that, at least for depression, there is little empirical support for DSM-III's suggestion that stress is a favorable prognostic sign.     

Biological measures and cellular immunological function in depressed psychiatric inpatients

Thirty depressed psychiatric inpatients, including 18 with a diagnosis of major depression, and 25 hospital staff controls were compared with respect to cellular immune function--that is, mitogen responsiveness to concanavalin A (con A), phytohemagglutinin (PHA), and pokeweed mitogen (PWM); natural killer cell (NK) activity; and T cell subsets, including helper/inducer T cells (CD4) and suppressor/cytotoxic cells (CD8). Only physically healthy subjects, who had not used psychoactive medications (except for low dose benzodiazepines) or other medications known to affect the immune system for at least 14 days, were included. Paired comparisons of the immune measures of patients with a DSM-III diagnosis of major depression (n = 18) with their controls demonstrated a statistically significant reduction of the patients' con A response. In addition, the patients with major depression had significantly lower con A and PHA responses than the combined patients with other forms of depression (atypical, dysthymic, or atypical bipolar). There was no indication that severity of depression, dexamethasone suppression test status, benzodiazepine use, or age accounted for the differences in immune function. A possibly important, unexpected finding was that antihistamine use was associated with lower immune function.     

Borderline personality disorder and bipolar II disorder in private practice depressed outpatients

Bipolar II disorder (BDII) may be confused with borderline personality disorder (BPD) when it is cyclothymic between episodes. The aim of the present study was to determine the prevalence of BPD and to test whether BDII can be distinguished from BPD without difficulty in private practice mood disorder outpatients. Private practice was chosen because it is often the first or second line of treatment of mood disorders in Italy, and many "soft" patients can be found in this setting. Among 63 consecutive unipolar and 50 bipolar II major depressive episode (MDE) outpatients interviewed with the Structured Clinical Interviews for DSM-IV axis I/II disorders (SCIDs), the prevalence of BPD was 6.1% and was significantly higher in BDII patients (12% v. 1.5%). Overall, the rate of BPD diagnosis was very low. BDII was distinguished from BPD without difficulty by DSM-IV criteria. The results suggest that there may be a subgroup of BDII patients with a relatively stable course between episodes (or at least not so unstable as to suggest a BPD diagnosis or comorbidity) and a low comorbidity with BPD, in a setting closer to community patients than university settings. The "usual" BDII patient can be distinguished from the BPD patient.     

Narcissistic personality disorder. A validity study and comparison to borderline personality disorder

Seventeen former inpatients with NPD were retrospectively compared to 19 patients with schizophrenia, 26 with MAD and 33 patients with BPD in terms of longitudinal course and outcome, exploring the validity of the NPD diagnosis. Two illustrative cases were presented. Results suggest that NPD is a valid diagnostic entity, more distinct from schizophrenia than MAD. NPD probably differs from BPD in terms of equal sex distribution in NPD; poor social functioning, especially in the low level of satisfaction with heterosexual relationships in NPD at follow-up; more rehospitalization in NPD; probably poorer global functioning in NPD at admission; and probably poorer overall follow-up functioning in NPD.     

The structure of post-traumatic stress disorder symptoms in three female trauma samples: a comparison of interview and self-report measures

Empirical research increasingly suggests that post-traumatic stress disorder (PTSD) is comprised of four factors: re-experiencing, avoidance, numbing, and hyperarousal. Nonetheless, there remains some inconsistency in the findings of factor analyses that form the bulk of this empirical literature. One source of such inconsistency may be assessment measure idiosyncrasies. To examine this issue, we conducted confirmatory factor analyses of interview and self-report data across three trauma samples. Analyses of the interview data indicated a good fit for a four-factor model across all samples; analyses of the self-report data indicated an adequate fit in two of three samples. Overall, findings suggest that measure idiosyncrasies may account for some of the inconsistency in previous factor analyses of PTSD symptoms.     

Ten-year stability of depressive personality disorder in depressed outpatients

OBJECTIVE: The purpose of this study was to examine the long-term stability of depressive personality disorder. METHOD: The subjects included 142 outpatients with axis I depressive disorders at study entry; 73 had depressive personality disorder. The patients were assessed by using semistructured diagnostic interviews at baseline and in four follow-up evaluations at 2.5-year intervals over 10.0 years. Follow-up data were available for 127 (89.4%) of the patients. RESULTS: The 10.0-year stability of the diagnoses of depressive personality disorder was fair, and the rate of depressive personality disorder declined over time. The dimensional score was moderately stable over 10.0 years. Growth curve analyses revealed a sharp decline in the level of depressive personality disorder traits between the baseline and 2.5-year assessments, followed by a gradual linear decrease. Reductions in depressive personality disorder traits were associated with remission of the axis I depressive disorders. Finally, depressive personality disorder at baseline predicted the trajectory of depressive symptoms over time in patients with dysthymic disorder. CONCLUSIONS: Depressive personality disorder is moderately stable, particularly when assessed with a dimensional approach. However, the diagnosis rate and traits of depressive personality disorder tend to decline over time. The degree of stability for depressive personality disorder is comparable to that for the axis II disorders in the main text of DSM-IV. Finally, depressive personality disorder has prognostic implications for the course of axis I mood disorders, such as dysthymic disorder.     

Nursing care of inpatients with borderline personality disorder

TOPIC. This paper reviews the current literature on the nursing care of inpatients with borderline personality disorder (BPD). Information is included about the background and various features of BPD, and recent conceptualizations and predicted outcomes for BPD patients are provided. The effect of caring for patients with BPD on the nursing staff is discussed. CONCLUSIONS. With proper education, support, and clinical supervision, the difficulties of caring for patients with BPD for the nursing staff can be reduced, and beneficial outcomes can be achieved for the staff and patients. NURSING IMPLICATIONS. Patients with BPD can impact the entire multidisciplinary team. Understanding the dynamics of patients with BPD helps the staff to develop strategies to avoid splitting, acting-out behaviors, and negative impact on other patients and staff.     

Reliability and validity of the structured interview for personality disorders in adolescents

The Structured Interview for the DSM-III Personality Disorders was administered to 23 currently affectively ill adolescents and their parents. Interviews were videotaped and rerated; interrater agreement was moderate (weighted K = 0.49; unweighted K = 0.59). Moreover, there was evidence of convergent validity for Cluster II traits and disorders (borderline, histrionic, narcissistic), insofar as these diagnoses were associated with higher scores on the novelty-seeking subscale of the Tridimensional Personality Questionnaire as predicted. Cluster II patients tended to have higher rates of attention deficit disorder and bipolar disorder, and higher rates of suicidal gestures among second-degree relatives. Some difficulty was encountered differentiating symptoms of affective illness from those of personality disorder and in deciding when personality traits were impairing enough to call them disorders. Reliability may be improved by: (1) interviewing patients when out of affective episode; and (2) using standardized functional impairment criteria for differentiating personality style from disorder. Additional work is advocated to learn if personality disorders are precursors, epiphenomena, or the consequences of affective disorder.     

Body image and borderline personality disorder among psychiatric inpatients

Objective

With the exclusion of studies in individuals with eating disorders, few investigators have examined body image issues in patients with borderline personality disorder (BPD). In this study, we examined among psychiatric inpatients relationships between body image and BPD.

Method

In a cross-sectional sample of convenience, we surveyed 126 women in an inpatient psychiatric unit using 5 measures for body image and 2 measures for BPD.

Results

Using standardized cutoffs for BPD diagnosis, participants with BPD demonstrated a number of differentiating features with regard to body image issues. Explicitly, BPD did not seem to be related to being self-conscious about one's appearance, although BPD was related to being more self-conscious, in general. Individuals with BPD were not more invested in their appearance as a source of self-definition but evaluated their own appearance more negatively and were more likely to believe that attractiveness is an important factor for happiness and acceptance. Although BPD was not related to perceptions about the strength and competence of one's own body, those with BPD indicated less comfort and trust in their own bodies. In general, it appeared that body image measures that were more perceptually grounded were more likely to be similar to non-BPD participants, whereas body image measures that were more cognitively grounded were more likely to be statistically significantly different in comparison with non-BPD participants.

Conclusions

Psychiatric inpatients with BPD demonstrate a number of disturbances in body image.     

The frequency of multiple personality disorder among psychiatric inpatients

OBJECTIVE: A 2-year study was undertaken to determine the frequency of multiple personality disorder among general adult psychiatric inpatients. METHOD: All individuals admitted to two 23-bed acute care wards in a teaching hospital in Winnipeg, Man., were screened with the Dissociative Experiences Scale. Individuals with prior diagnoses of multiple personality disorder were excluded. All subjects scoring 20 or higher on the Dissociative Experiences Scale were interviewed with the Dissociative Disorders Interview Schedule. Then subjects with a diagnosis of multiple personality disorder and comparison subjects were interviewed by a clinician who was blind to all research data. RESULTS: A total of 299 subjects completed the Dissociative Experiences Scale and 80 received a structured diagnostic interview. Ten subjects (3.3%) had clinically confirmed multiple personality disorder. CONCLUSIONS: If these results are replicated and accepted, multiple personality disorder will become a serious consideration in the differential diagnosis of many psychiatric patients.     

Persistent social dysfunction in anxious and depressed patients with personality disorder

OBJECTIVE: To determine the long-term social function of psychiatric patients with anxiety and depressive disorders and to relate this to personality status and other factors. METHOD: A cohort of 210 patients (mean age 35 years) with dysthymic disorder, generalized anxiety disorder or panic disorder diagnosed using a structured interview (SCID) were assessed at baseline for personality status using the Personality Assessment Schedule (PAS) and ratings of anxiety and depression. Exactly 12 years later social function was assessed using the Social Functioning Questionnaire (SFQ) and personality reassessed with the PAS by a rater blind to initial personality status. Individual social function items were examined in those with and without personality disorders. RESULTS: Social function was significantly better in those with little or no baseline personality disturbance (P < 0.001) and the domains of close relationships, stress in completing tasks, use of spare time and family relationships showed the largest personality differences. A multiple linear regression model showed that self-rated depression scores, single marital status and personality status were the main baseline variables predicting social function at 12 years. CONCLUSION: Although personality characteristics may change over time social dysfunction persists and persistent social dysfunction in mental state disorders may be a strong indicator of personality disturbance rather than an indicator of treatment resistance.     

Sadistic personality disorder and comorbid mental illness in adolescent psychiatric inpatients

Sadistic personality disorder (SPD) is a controversial diagnosis proposed in the DSM-III-R, but not included in the DSM-IV. Few studies have focused on this disorder in adolescents. This article describes the results of a study that sought to determine the presence of sadistic personality characteristics in psychiatrically hospitalized adolescents and of comorbid Axis I or personality disorder patterns in those youth with SPD or SPD traits. Fifty-six adolescents were assessed for sadistic and other personality disorders with the Structured Interview for DSM-III-R Personality Disorders-Revised (SIDP-R). Axis I disorders were assessed using the Diagnostic Interview for Children and Adolescents, Adolescent Version (DICA-R-A) and portions of the Schedule for Affective Disorders and Schizophrenia for School Age Children, Epidemiologic (K-SADS-E). The youth were divided into those with SPD and SPD traits, the Sadistic Group (n = 18), and the Nonsadistic Group (n = 38). A significant proportion of the adolescents in this study met full DSM criteria for SPD (14%). The Sadistic Group (32%) had significantly more Axis I and personality pathology than did the Nonsadistic Group. However, all but one in the Sadistic Group met criteria for other personality disorders, confounding the interpretation of these findings and consistent with adult literature studies. Subjects with sadistic personality characteristics were identified in this adolescent inpatient sample, and they had more extensive Axis I and II psychopathology than the comparison group. The validity of this disorder in younger populations requires further study. Future studies should also explore the impact that the mandatory use of the pleasure/gratification criterion has on the validity of the SPD diagnosis and whether the requisite presence of this criterion decreases the overlap currently noted between SPD and other Axis II diagnoses.     

The validity of a self-report questionnaire for diagnosing major depressive disorder

Six hundred thirteen first-degree relatives of schizophrenics, depressives, and normal controls were interviewed with the Diagnostic Interview Schedule (DIS) and completed the Inventory to Diagnose Depression (IDD), a self-report scale to diagnose major depressive disorder (MDD). The current point prevalence of MDD was nearly identical according to the two measures (DIS, 2.8%; IDD, 2.6%). Diagnostic concordance varied according to the Interval between the evaluations. When the two measures were completed within two days of each other the agreement was as high as can be expected between two instruments with less than perfect reliability. We used a family study approach to examine validity and found that both the DIS and IDD cases of depression were two to three times more frequent in the relatives of depressed patients than the relatives of schizophrenics and controls.