Personality disorder assessment for psychiatric inpatients

The standardised criteria for DSM-III personality disorders encouraged the development of numerous multidimensional instruments to make the diagnosis of such disorders more objective and reliable compared with clinical judgement. Yet, there is no published research on the concordance between these instruments when used with psychiatric inpatients. Two such measures, the Millon Clinical Multiaxial Inventory (MCMI) and the Structured Interview for DSM-III Personality (SIDP), were chosen for this study. The MCMI identified a significantly greater number of personality disorders than the SIDP for each subject. Despite overall high interrater reliability with the SIDP, low agreement was found between the two instruments for most of the 11 DSM-III Axis II (personality disorders) categories. Different normative populations on which the instruments were developed, method variance, and theoretical differences between Millon and DSM-III, were all likely to contribute to the low concordance. Systematic research of possible confounding factors is suggested.     

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.     

DSM-III symptom disorders (Axis I) and personality disorders (Axis II) in an outpatient population

Type and prevalence of Axis I and Axis II disorders (DSM-III) were assessed in a sample of 298 consecutive psychiatric outpatients. The instruments used were SCID and SIDP. About half of the Axis I diagnoses consisted of different subgroups of depression. Most patients had more than one diagnosis, anxiety being the second most common disorder. Eighty one percent of the subjects met the criteria for a personality disorder diagnosis; half of them obtained more than one Axis II diagnosis. Personality disorder was more common among men than among women. Avoidant and dependent personality disorders constituted the most frequent diagnoses.     

Frequency of DSM-III personality disorders in patients with panic disorder: comparison with psychiatric and normal control subjects

Three clinical populations--panic disorder (n = 88), randomly selected outpatients (n = 82), and normal control subjects (n = 40)--were compared on three standardized DSM-III personality disorder instruments, the Structured Interview for DSM-III Personality Disorders (SIDP), the Millon Clinical Multiaxial Inventory (MCMI), and the Personality Diagnostic Questionnaire (PDQ). Significant differences were consistently found in presence of "any" personality disorder and DSM-III Cluster C (there were always more disorders in the outpatients). Logistic regression analysis revealed the important determinants predicting personality disorders, and therefore of differences between groups, were state depression, age, lifetime history of alcohol abuse, and presence of panic disorder.     

Personality and personality disorders among patients with major depression in combination with dysthymic or cyclothymic disorders

Personality traits and personality disorders in 298 consecutive outpatients with pure major depression, major depression with dysthymic or cyclothymic disorder, pure dysthymic or cyclothymic disorder and other disorders were investigated. Patients with dysthymic or cyclothymic disorders alone or in combination with major depression showed more self-doubt, insecurity, sensitivity, compliance, rigidity and emotional instability. They were more schizoid, schizotypal, borderline and avoidant according to MCMI and had a higher prevalence of DSM-III Axis II diagnoses, and more borderline, avoidant, and passive-aggressive personality disorders, as measured by SIDP. All in all, dramatic and anxious clusters of personality disorders were more frequent among patients with dysthymic-cyclothymic disorders in addition to major depression than among patients with major depression only. The findings elucidated the close connection between the more chronic affective disorders and the personality disorders, irrespective of any concomitant diagnosis of major depression.     

Concordance between two personality disorder instruments with psychiatric inpatients

Eighty-two psychiatric inpatients received axis II diagnoses on the Millon Clinical Multiaxial Inventory (MCMI-1)--a self-report instrument--and the Structured Interview for DSM-III Personality (SIDP). Those two instruments were then compared in terms of personality disorder categories and trait-scores (dimensions). Essentially, with the exception of the borderline category, concordance between the two instruments was poor on all scales. Bayesian statistics confirmed the obtained results. The adequacy of the MCMI-I as an index of DSM-III personality disorders is questioned.     

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.     

Personality disorders in anorexia nervosa and bulimia nervosa

Two self-report questionnaires (MCMI and BSI) designed to measure personality disorder (PD) according to DSM-III (R) criteria were administered to patients with a diagnosis of anorexia nervosa (AN) (n = 19), bulimia nervosa (BN) (n = 16), or both diagnoses (AN + BN) (n = 9), both before and after treatment for the eating disorder. The main finding was that self-reported Personality Disorder (PD) diagnoses are not stable enduring characteristics among this group of eating disorder patients. A high rate of PD diagnoses occurred in all patient groups at admission (93%) and at discharge (79%). Both MCMI and BSI scales were subject to significant change following treatment. A high prevalence of borderline personality disorder was found in patients with BN. Changes in depression and self-esteem scores correlated most strongly with changes in schizoid, schizotypal, histrionic and narcissistic scales. Assessment of PD using self-report measures should be interpreted with caution in acutely symptomatic patients with eating disorders.     

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.     

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.     

The longitudinal course of borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder

OBJECTIVE: The syndromal and subsyndromal phenomenology of borderline personality disorder was tracked over 6 years of prospective follow-up. METHOD: The psychopathology of 362 inpatients with personality disorders was assessed with the Revised Diagnostic Interview for Borderlines (DIB-R) and borderline personality disorder module of the Revised Diagnostic Interview for DSM-III-R Personality Disorders. Of these patients, 290 met DIB-R and DSM-III-R criteria for borderline personality disorder and 72 met DSM-III-R criteria for other axis II disorders (and neither criteria set for borderline personality disorder). Most of the borderline patients received multiple treatments before the index admission and during the study. Over 94% of the total surviving subjects were reassessed at 2, 4, and 6 years by interviewers blind to previously collected information. RESULTS: Of the subjects with borderline personality disorder, 34.5% met the criteria for remission at 2 years, 49.4% at 4 years, 68.6% at 6 years, and 73.5% over the entire follow-up. Only 5.9% of those with remissions experienced recurrences. None of the comparison subjects with other axis II disorders developed borderline personality disorder during follow-up. The patients with borderline personality disorder had declining rates of 24 symptom patterns but remained symptomatically distinct from the comparison subjects. Impulsive symptoms resolved the most quickly, affective symptoms were the most chronic, and cognitive and interpersonal symptoms were intermediate. CONCLUSIONS: These results suggest that symptomatic improvement is both common and stable, even among the most disturbed borderline patients, and that the symptomatic prognosis for most, but not all, severely ill borderline patients is better than previously recognized.     

The diagnostic interview for personality disorders: Interrater and test-retest reliability

The Diagnostic Interview for Personality Disorders (DIPD) is a semistructured interview of 252 questions that encompasses all 11 Axis II disorders described in the DSM-III. Its interrater reliability was assessed using a sample of 43 patients and its test-retest reliability was assessed using a separate sample of 54 patients. Adequate kappas were obtained in both situations for all disorders except schizoid personality disorder, which was never diagnosed. Interrater coefficients ranged from .52 to 1.0, with nine in the excellent range (κ > .75). Test-retest coefficients ranged from .46 to .85, with four in the excellent range. These results compara very favorably to those achieved using the other two Axis II interviews that have appeared in the literature, the Structured Interview for the DSM-III Personality Disorders (SIDP) and the Personality Disorder Examination (PDE).     

ECT response in depressed patients with and without a DSM-III personality disorder

Twenty-five inpatients with DSM-III major depressive disorder received ECT and were interviewed with the Structured Interview for DSM-III Personality Disorders. Patients with and patients without a personality disorder had similar short-term responses to ECT. The results of a 6-month prospective follow-up showed that depressed patients with a personality disorder were significantly more symptomatic and eight times more likely to be rehospitalized.     

Trait-state artifacts and the diagnosis of personality disorders

The multiaxial nature of DSM-III has stimulated interest in the personality disorders. There are also indications that it has produced an increase in their diagnosis. However, there is clinical and psychometric evidence that a personality evaluation undertaken while a patient is in a dysphoric mental state may distort or misrepresent traits, the so-called trait-state problem in personality assessment. The present study appears to be the first to investigate this phenomenon with a clinical interview rather than with personality tests. It examined the effect of anxiety, depression, and level of global impairment on the diagnosis of personality disorder and the assessment of the criteria for the individual Axis II disorders. Eighty-four patients, most of whom had current Axis I diagnoses, were evaluated by seven experienced clinicians with a new semistructured interview, the Personality Disorder Examination. The sample evidenced a trend toward acknowledging fewer maladaptive personality traits at follow-up than at entry. There was no evidence, however, that anxiety or depression had affected either the diagnosis of a personality disorder or the criteria associated with most of the individual personality disorders.     

The relationship between syndrome and personality disorder in DSM-III: experience with 2,462 patients

The authors studied the relationship between DSM-III axis I and axis II diagnoses in 2,462 medical center patients. Personality disorders were most commonly associated with substance use disorders and with the anxiety and somatoform disorders traditionally classified as neuroses. There was a particularly strong connection between antisocial personality disorder and substance abuse. The psychotic and major affective illnesses were significantly less often associated with personality disorders. The results of this study suggest a need for refining the criteria for several DSM-III categories. Overall, the separate personality disorder axis in the DSM-III system provides information not contained with the syndromal classification alone.     

Effect of axis II diagnoses on treatment outcome with clomipramine in 55 patients with obsessive-compulsive disorder.

We used the Structured Interview for DSM-III Personality Disorders to diagnose DSM-III personality disorders systematically in 55 patients with obsessive-compulsive disorder in the active-treatment cell of a controlled trial of clomipramine hydrochloride. Patients with a cluster A personality disorder had significantly higher obsessive-compulsive disorder severity scores at baseline, and the number of personality disorders was strongly related to baseline severity of obsessive-compulsive disorder symptoms. At the conclusion of the 12-week study, we found no significant difference in treatment outcome with clomipramine between those patients with at least one personality disorder and those with no personality disorders. However, the presence of schizotypal, borderline, and avoidant personality disorders, along with total number of personality disorders, did predict poorer treatment outcome. These variables were strongly related to having at least one cluster A personality disorder diagnosis, which was also a strong predictor of poorer outcome. Implications of these findings are discussed.     

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.     

A comparison of DSM-III personality disorders in panic/agoraphobia and obsessive-compulsive disorder

One hundred eighty-seven patients meeting DSM-III criteria for panic disorder (161 with agoraphobia) and 51 patients meeting DSM-III criteria for obsessive-compulsive disorder (OCD) were assessed with the Personality Diagnostic Questionnaire (PDQ), a self-rating scale designed to assess axis II personality disorders and traits. The results showed that the personality profiles were similar between the two diagnostic groups and that the major personality characteristics identified in panic/agoraphobic patients, e.g., avoidant, dependent, histrionic, and borderline, were more pronounced in patients with OCD. These findings support our earlier suggestion of a nonspecific link between panic disorder/agoraphobia and personality disorder (PD)/traits.     

Anxiety and depression: comorbidity, psychopathology, and social functioning

A sample of 48 former nonpsychotic inpatients was studied with respect to the overlap of depression and anxiety. Particular emphasis was placed on social dysfunctions associated with anxiety disorder as both a pure and a mixed condition. Furthermore, another question examined was whether social dysfunctions represent a risk factor for the development of a severe depression. Almost 40% of patients with a DSM-III anxiety disorder (during the last 4 weeks before follow-up) simultaneously fulfilled the criteria of a depressive disorder, mainly those of a major depression. While the course of symptomatology for both the pure anxiety and the mixed group had been rather similar over a long period of time, social dysfunctions before index admission had been generally more pronounced in patients who later developed a severe secondary depression. Social dysfunctions of patients with both disorders are not exclusively explainable by a higher severity of symptoms or the presence of particular personality features.     

Personality disorders in patients with winter depression

Sixty-six patients satisfying the criteria for seasonal affective disorder (SAD) winter depression type (n= 57) or subsyndromal SAD (n= 9), were interviewed in a nondepressed state with the Structured Interview for DSM-III-R Personality Disorders (SIDP-R). Twenty-three percent of the patients in the SAD sample met DSM-III-R criteria for one or more categorical diagnosis of personality disorder (PD). Disorders in cluster C occurred in 18% of the sample, while 12% had cluster B PDs and 5% a cluster A disorder. The relative number of positive criteria, as a dimensional measure of PD, were higher for all cluster C disorders than for any PD in the other clusters. Our data indicate that the pattern of personality disorders in patients with winter SAD are similar to that previously reported for outpatients with non-SAD major depression. We explored the relationship between lifetime severity and clinical manifestation of SAD and dimensional measures of PD with multiple regression analyses. No significant association was found. This is in accordance with the hypothesis that the two disorders are distinct conditions with independent causes.