What dimensions underlie cluster B personality disorders?

This report presents a conceptual model of the relationships between personality dimensions and the four personality disorders listed in the B cluster on axis II. The hypothesis will be developed that while impulsivity is the common dimension underlying all four disorders, differences between the categories reflect the severity of impulsive traits, interactions with other personality dimensions, the effects of gender, and the influence of culture. Clinical and research implications of the model are then described.     

Are there gender differences in DSM-IV personality disorders?

This study examined gender differences in DSM-IV personality disorders (PD) in outpatients. Structured diagnostic interviews were reliably administered to a consecutive series of 145 outpatients with a primary axis I diagnosis of binge eating disorder (BED). To further reduce variability due to heterogeneity of axis I, a subgroup of 75 patients with co-occurring major depressive disorder (MDD) was retested for gender differences. Overall, the proportion of males (34.4%) and females (27.4%) diagnosed with any PD did not significantly differ. Specific PD diagnoses were not differentially distributed by gender in the overall study group of patients with BED or in the subgroup of patients with BED and MDD, except for antisocial PD in males.     

What do all personality disorders have in common? Ineffectiveness and uncooperativeness

We still lack operative and theoretically founded definitions of what a personality disorder (PD) is, as well as empirically validated and feasible instruments to measure the disorder construct. The Temperament and Character Inventory (TCI) is the only personality instrument that explicitly distinguishes personality style and disordered functioning. Here, we seek to (1) confirm in a clinical sample that the character dimensions of the TCI capture a general construct of PD across all specific PD subtypes, (2) determine whether such core features can be used to detect the presence of PD, and (3) analyze whether such detection is affected by the presence and severity of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) Axis I symptoms. Two hundred five anxious/depressed outpatients were evaluated with the Structural Clinical Interview for DSM-IV Axis I and II Disorders. Assessment also included the TCI, the Hamilton rating scales for depression and anxiety, and the Panic and Agoraphobia Scale. Sixty-one patients (29.8%) were diagnosed as having a DSM-IV PD. Self-directedness and Cooperativeness, but no other TCI dimensions, predicted the presence of PD (Nagelkerke R(2) = 0.35-0.45) and had a moderate diagnostic utility (kappa = 0.47-0.58) when Axis I symptoms were absent or mild. However, accuracy decreased in anxious or depressed patients. Our study supports the hypothesis of a disorder construct that is not related to the intensity of any specific PD subtype but which is common to all PDs. This construct relies largely on internal representations of the self revealing ineffectiveness and uncooperativeness.     

Borderline or bipolar? Distinguishing borderline personality disorder from bipolar spectrum disorders

This article addresses the question whether borderline personality disorder (BPD) can be understood as a variant of bipolar disorder. In the past, borderline pathology has been seen as a variant of psychosis, depression, or posttraumatic stress disorder, but there are important differences between all of these conditions and BPD. The proposal that BPD falls within the bipolar spectrum depends on the assumption that affective instability develops through the same mechanism in both diagnostic categories. There are major differences in phenomenology, family history, longitudinal course, and treatment response between BPD and bipolar disorder, and the findings of comorbidity studies are equivocal. Thus, existing evidence is insufficient to support the concept that BPD falls in the bipolar spectrum.     

Avoidant personality disorder and social phobia: distinct enough to be separate disorders?

OBJECTIVE: Existing evidence from anxiety disorder research indicates that social phobics (SP) with avoidant personality disorder (AVPD) experience more anxiety and show more impairment than patients with SP alone. The purpose of this study was to examine whether in patients diagnosed with AVPD, the co-occurrence of SP adds to its severity. We hypothesized that the addition of SP will not add to the severity of AVPD alone. METHOD: Two groups of patients (AVPD=224; AVPD/SP=101) were compared at baseline and 2 years later on multiple demographic and clinical variables. RESULTS: Patients with AVPD and an additional diagnosis of SP differed little from patients with AVPD alone. CONCLUSION: These findings suggest that AVPD and SP may be alternative conceptualizations of the same disorder.     

Categorical versus dimensional classification of personality disorders: are dimensional models the future?

The classification of personality disorders (PD) according to ICD-10 and DSM-IV has been critisized for several reasons. For example, those who have attempted to validate the presence of a non-arbitrary distinction between normal and abnormal personality functioning have suggested that no such distinction exists. Furthermore, PDs frequently co-occur with a number of Axis-I conditions and other Axis-II disorders leading to multiple diagnoses. Therefore, many have suggested classifying PDs dimensionally, rather than categorically. However, there are only a few studies that have investigated the applicability of these models with respect to PDs, and most of these studies used the Big Five. In this study we investigated the applicability of the Seven-Factor model of temperament and character for the classification of PDs. Our results show that the Seven-Factor model discriminates well between PDs and healthy controls, as well as between PDs and Axis-I disorders. We discuss our findings and present a modified scheme to diagnose PDs.     

Antisocial personality disorder in patients with substance abuse disorders: a problematic diagnosis?

The authors' literature review suggests that the relationship between antisocial personality disorder and substance abuse is complex and not yet fully understood. The confusion regarding the relationship between the disorders may be magnified by the emphasis in DSM-III and DSM-III-R on behavioral criteria and their failure to require that antisocial behaviors exist independently of substance abuse. The DSM-III and DSM-III-R formulations of antisocial personality disorder may encompass two subgroups of substance abusers--"true" psychopathic individuals and symptomatic psychopaths with little psychopathy. Psychoneurotic symptoms and favorable treatment responses might be found more often in the latter group.     

Experienced therapists’ opinions on central issues in psychodynamic psychotherapy of patients with personality disorders

Individual psychodynamic psychotherapy is a recommended, but controversial, treatment for patients with personality disorders (PDs). The aim of this study was to examine the relationship between demographic and professional characteristics of experienced psychotherapists and their attitudes and opinions towards aspects of this kind of psychotherapy. A questionnaire covering these issues of psychodynamic psychotherapy with patients belonging to all three DSM-IV clusters of PD was developed. A sample of 324 Norwegian psychiatrists and clinical psychologist with considerable experience in individual dynamic psychotherapy of patients with PDs filled in valid questionnaires. The therapists’ age, gender, profession, postgraduate courses and degree of experience were examined as to their opinions on the following issues: alliances, aims, contraindications, needs to terminate, suicides, use of drugs, length of treatment, need for supervision and complaints to colleagues about patients’ behaviour in such therapy with PD patients. Independent sample t-tests of the mean z-transformed group scores were the main statistical method applied. Therapist experience made the most significant differences as to treatment issues, while some differences also were found for age, gender and profession. The influence of postgraduate courses was negligible. Our study might have a selection bias towards therapist with strong psychodynamic orientation and particular interest in the psychotherapy of patients with PDs.     

Short-term day treatment programmes for patients with personality disorders. What is the optimal composition?

Research evidence indicates that approximately 10 h a week is a sufficient intensity for short-term day treatment programmes for patients with personality disorders. In this article, we discuss which therapeutic components should be included in such a programme. Relevant research and clinical literature are reviewed. The fit between the therapeutic components and the programme as a whole is discussed according to: 1) scientific evidence of the effectiveness of the therapeutic components, 2) a sound theoretical rationale, 3) evidence of user satisfaction among patients, 4) clinical experiences of staff, 5) comprehensiveness and consistency, and 6) available therapeutic skills and resources. We advocate an 11-h treatment programme comprising small group psychotherapy, art group therapy, large group psychotherapy, cognitive group therapy, problem-solving group therapy and optional adjuncts (cognitive behavioural group therapy) for patients with additional anxiety and eating disorders.