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.     

Factor structure of DSM-IV criteria for obsessive compulsive personality disorder in patients with binge eating disorder

OBJECTIVE: To examine the factor structure of DSM-IV criteria for obsessive compulsive personality disorder (OCPD) in patients with binge eating disorder (BED). METHOD: Two hundred and eleven consecutive out-patients with axis I diagnoses of BED were reliably assessed with semi-structured diagnostic interviews. The eight criteria for the OCPD diagnosis were examined with reliability and correlational analyses. Exploratory factor analysis was performed to identify potential components. RESULTS: Cronbach's coefficient alpha for the OCPD criteria was 0.77. Principal components factor analysis with varimax rotation revealed a three-factor solution (rigidity, perfectionism, and miserliness), which accounted for 65% of variance. CONCLUSION: The DSM-IV criteria for OCPD showed good internal consistency. Exploratory factor analysis, however, revealed three components that may reflect distinct interpersonal, intrapersonal (cognitive), and behavioral features.     

Childhood maltreatment and personality disorders in adult patients with binge eating disorder

OBJECTIVE: To examine the association between retrospective reports of different types of childhood maltreatment and current personality disorders (PDs) in patients with binge eating disorder (BED). METHOD: A total of 116 consecutive out-patients with DSM-IV BED were assessed with diagnostic interviews and completed the Childhood Trauma Questionnaire to assess childhood maltreatment in five domains (emotional abuse, physical abuse, sexual abuse, emotional neglect and physical neglect). RESULTS: Eighty-two percent of patients reported some form of childhood maltreatment and 30% met criteria for at least one PD. Emotional abuse was significantly associated with cluster C PD overall and specifically with avoidant PD. CONCLUSION: Reports of emotional abuse - but not other forms of maltreatment - were associated with greater likelihood of a PDs in patients with BED.     

Applicability of Personality Disorder Criteria to Hospitalized Adolescents: Evaluation of Internal Consistency and Criterion Overlap

ObjectiveThe authors examined the applicability of personality disorder criteria to adolescent inpatients by evaluating internal consistency and criterion overlap.MethodThirty-eight adolescents and 28 adults were assessed with the Personality Disorder Examination. Within-category cohesiveness (internal consistency) of the criteria was evaluated by examining intercriterion correlations as well as coefficient α. In addition, between-category criterion overlap was evaluated by examining “intercategory” intercriterion correlations between all pairs of disorders. Separate analyses were conducted for adolescents and adults, and the groups were compared.ResultsInternal consistency appeared to be lower in adolescents, as measured by intercriterion correlation and coefficient α, with the largest differences being identified for most cluster B disorders. Intercategory analysis indicated that criterion overlap may be greater among adolescents.ConclusionsOverall, this psychometric analysis suggests that there may be limitations to the DSMs approach to categorizing personality disorders. For both adolescents and adults, modest degrees of within-category cohesiveness (internal consistency) and between-category criterion overlap were observed. Comparatively, personality disorder criteria in adolescents tended to have lower internal consistency and less discriminant validity. The data raise questions about the construct validity of these disorders—or the applicability of these criteria—within this age group.     

Disentangling depressive personality disorder from avoidant, borderline, and obsessive-compulsive personality disorders

Several studies have found that 3 personality disorders (PDs) tend to share moderate rates of comorbidity with depressive PD: avoidant, borderline, and obsessive-compulsive. This study sought to evaluate the diagnostic criteria of each disorder in an effort to understand where areas of overlap may occur and to modify criteria sets where reasonable to reduce any degree of overlap. One thousand two hundred psychiatric outpatients were interviewed with the Structured Interview for DSM-IV Personality Disorders. The highest degree of comorbidity was observed between avoidant PD and depressive PD. Logistic regression analyses indicated that 2 criteria-avoidant criterion 5 and depressive criterion 2-could be removed from the diagnostic criteria sets and reduce the rates of overlap by as much as 15%. A factor analysis of the criteria of all 4 PDs indicated that there is a common clustering of many of the symptoms of avoidant, borderline, depressive, and obsessive-compulsive PDs and that borderline symptoms tend to cluster together most consistently. Avoidant and obsessive-compulsive personality symptoms clustered in ways that may reflect a problem of how to engage with others, suggestive of an approach-avoidance conflict. Depressive PD symptoms clustered in a way suggestive of problems with anger that is directed toward oneself and others. The factor analysis results suggest that an organization of symptoms around themes of conflict may provide useful ways of understanding the personality patterns of these 4 disorders.     

Electronic monitoring of antipsychotic medication adherence in outpatients with schizophrenia or schizoaffective disorder: an empirical evaluation of its reliability and predictive validity

This study examined the reliability and predictive validity of electronic monitoring (EM) in assessing the oral antipsychotic medication adherence of outpatients with schizophrenia or schizoaffective disorder. Sixty-one adult outpatients with schizophrenia or schizoaffective disorder who took a single oral antipsychotic medication were assessed monthly over a 6-month study period with EM of medication bottle opening. Symptom severity, as measured by the Positive and Negative Syndrome Scale (PANSS) total score, was assessed monthly over the 6-month study period. Cronbach's coefficient alpha revealed very high internal reliability (alpha=0.94). A high degree of test-retest reliability was found (beta ranged from 0.75 to 1.19 and r ranged from 0.63 to 0.90). As for predictive validity, greater mean EM adherence was significantly related to lower mean symptom severity.     

Validation of a revised visual analog scale for premenstrual mood symptoms: results from prospective and retrospective trials.

OBJECTIVE: Previous studies have demonstrated that visual analog scales (VASs) are valid and reliable instruments for measuring the severity of premenstrual symptoms. Most of these studies, though, predate the introduction of DSM-IV diagnostic criteria for premenstrual dysphoric disorder (PMDD). Our objective was to assess the reliability and validity of VASs that were revised to better reflect the DSM-IV definition of PMDD. METHODS: Concurrent information from the well-validated Premenstrual Tension Syndrome-Observer (PMTS-O) rating scale was used to evaluate the revised VASs. Data from 4 randomized controlled trials (n = 1208) evaluating the efficacy of paroxetine for the treatment of PMDD were used. Cronbach's alpha coefficient was used to evaluate the internal consistency of the core VAS mood items. Pearson's correlation between scores from the 2 scales was used to assess reliability. RESULTS: The internal consistency among the core VAS mood items (Cronbach's alpha > 0.90 across trials) was high. Luteal VAS scores and corresponding PMTS-O scores were moderately correlated at baseline (P < 0.01). Luteal VAS change scores and corresponding PMTS-O change scores were strongly correlated (P < 0.01). These results did not differ regardless of whether the PMTS-O data were collected prospectively or retrospectively. CONCLUSION: The revised VASs, which approximate the current DSM-IV definition of PMDD, provide a valid and reliable measure of the severity of premenstrual symptoms when evaluated against the validated PMTS-O scale. Our results also suggest that, whether observers assessed severity of PMDD symptoms retrospectively or prospectively using the PMTS-O scale, the correlations with the patient-reported VAS scores were comparable.     

The reliability and validity of a screening Questionnaire for 13 DSM-IV Axis I disorders (the Psychiatric Diagnostic Screening Questionnaire) in psychiatric outpatients.

BACKGROUND: The purpose of this study was to examine the reliability and validity of a new multidimensional screening instrument for 13 DSM-IV Axis I disorders. METHOD: The Psychiatric Diagnostic Screening Questionnaire (PDSQ) is a 90-item self-administered questionnaire that screens for 13 DSM-IV disorders in 5 areas (eating, mood, anxiety, substance use, and somatoform disorders). A consecutive series of 500 psychiatric outpatients completed the PDSQ immediately before their intake evaluation. Seventy-four patients completed the scale a second time less than a week after the initial administration, and 51 patients completed a booklet of questionnaires that included established measures of the same symptom domains assessed by the PDSQ. RESULTS: The PDSQ subscales achieved moderate-to-high levels of internal consistency (mean Cronbach's alpha coefficient = 0.82) and test-retest reliability (mean correlation coefficient = 0.84). Subscale scores were significantly associated with blind clinical diagnoses, and individual PDSQ items correlated much more highly with their own subscale than with other subscales. The PDSQ subscales were much more highly correlated with established measures of the same symptom domain (mean correlation coefficient = 0.72) than with measures of other types of psychopathology (mean correlation = 0.17). CONCLUSION: The PDSQ is a reliable and valid measure of multiple DSM-IV disorders that is brief enough to be incorporated into routine clinical outpatient practice without disruption, yet lengthy enough to be a psychometrically sound instrument.     

Clinical utility of DSM-IV pain disorder.

The utility of DSM-IV criteria for pain disorder was investigated within a consecutive sample of 90 chronic pain patients aged between 18 and 65 years. In this sample, 65.6% (n = 59) fulfilled diagnostic criteria for DSM-IV pain disorder. Of the patients with DSM-IV pain disorder, 22% fulfilled additional criteria for depressive disorder, 6.8% for hypochondriasis, and 23.7% for any other DSM-IV diagnosis. Only 54.2% of the patients with DSM-IV pain disorder had no comorbid psychiatric disorder. When assessing somatoform symptoms without hierarchical guidelines, there is a great overlap between the symptomatology of pain disorder and other somatoform disorders. Of 59 patients with DSM-IV pain disorder, 93.2% also met criteria for DSM-IV undifferentiated somatoform disorder and 10.2% for DSM-IV somatization disorder. The mean number of somatoform symptoms was 17 in the total sample. Despite the presence or absence of a general medical condition, there was no significant difference between pain disorder associated with both psychological factors and a general medical condition (code 307.89) and pain disorder associated with psychological factors (code 307.80) with regard to the pain duration, intensity, and type and the level of disability and educational level. The formulation of a distinct psychiatric entity for pain conditions may improve the consideration of psychosocial factors in the pathogenesis and clinical cause of pain. However, with regard to our data, the distinctive validity of different subtypes of pain disorder as provided by DSM-IV awaits further clarification.     

Which DSM-IV personality disorders are most strongly associated with indices of psychosocial morbidity in psychiatric outpatients?

The DSM-5 Work Group for Personality and Personality Disorders (PDs) recommended retaining 6 specific PD "types" (antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal) and eliminating the other 4 PDs currently included in DSM-IV (paranoid, schizoid, histrionic, and dependent). One important clinical aspect of PDs is their association with indices of psychosocial morbidity. Because the literature on the relationship between PDs and psychosocial morbidity in psychiatric patients is limited, we undertook the current analysis of the Rhode Island Methods to Improve Diagnostic Assessment and Services project database to examine which PDs were most strongly associated with a variety of measures of psychosocial morbidity. We tested the hypothesis that the disorders recommended for retention in DSM-5 would be associated with more severe morbidity than the disorders recommended for deletion. A total of 2150 psychiatric outpatients were evaluated with semistructured diagnostic interviews for DSM-IV Axes I and II disorders and 7 measures of psychosocial morbidity. We examined the correlation between each PD dimensional score and each measure of morbidity and then conducted multiple regression analyses to determine which PDs were independently associated with the indices of morbidity. For the 6 PDs proposed for retention in DSM-5, 36 (85.7%) of the 42 correlations were significant, whereas for the 4 PDs proposed for deletion, 26 (92.9%) of the 28 correlations were significant. In the regression analyses for the 6 PDs proposed for retention in DSM-5, 19 (45.2%) of the 42 β coefficients were significant, whereas for the 4 PDs proposed for deletion, 7 (25.0%) of the 28 β coefficients were significant. The results of the present study, along with the results of other studies, do not provide clear evidence for the preferential retention of some PDs over others based on their association with indices of psychosocial morbidity.     

Discriminant efficiency of antisocial and borderline personality disorder criteria in Hispanic men with substance use disorders

The authors examined the discriminant efficiency of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition ( DSM-IV ) criteria for borderline personality disorder (BPD) and antisocial personality disorder (APD). Subjects were 74 men admitted to an outpatient substance abuse program for monolingual Hispanic adults. All were reliably assessed with the Spanish-language version of the Diagnostic Interview for DSM-IV Personality Disorders. Conditional probabilities were calculated to determine the diagnostic efficiency and discriminant efficiency of BPD and APD symptoms. Twenty-five (34%) subjects met diagnostic criteria for BPD, and 16 (22%) met criteria for APD. The diagnostic co-occurrence of these disorders was statistically significant. Whereas the diagnostic efficiency of the BPD criterion set was comparable to that reported in other clinical studies, these criteria were not significantly more efficient in diagnosing BPD than APD. By contrast, the APD criteria were more efficient in diagnosing APD than BPD; this was true for both the "adult" and the "conduct disorder" APD criterion subsets. In male Hispanic outpatients with substance use disorders, BPD and APD show significant diagnostic overlap. The APD criteria are useful in discriminating these 2 disorders, whereas the BPD criteria are not. These findings have implications for the discriminant validity of the BPD and APD criteria and support the value of the conduct disorder criteria in predicting APD in adulthood.     

Defense mechanisms and personality disorders

The evaluation of defense mechanisms represents one of the most promising fields in the psychodynamic-oriented empirical research on personality disorders (PDs). This study examines the association between DSM-IV PDs and defense mechanisms. We evaluated a sample of 50 adult outpatients seeking personality assessment and psychotherapeutic treatment. PDs have been assessed using the Structured Clinical Interview for DSM-IV Personality Disorder, version 2.0. Defense mechanisms have been evaluated by a group of trained clinical psychologists and psychiatrists (interrater reliability from .61 to .95) using Perry's Defense Mechanism Rating Scale. Our results support the hypothesis that some defense mechanisms underlie PDs and that defenses call for further attention as we assess PDs.     

Comparison of patients with bulimia nervosa, obese patients with binge eating disorder, and nonobese patients with binge eating disorder

This study compared patients with bulimia nervosa (BN), obese patients with binge eating disorder (BED), and nonobese patients with BED. One hundred sixty-two adult women consecutively evaluated for outpatient clinical trials who met DSM-IV criteria for BN, purging type (N = 46) or for BED (N = 79 obese and N = 37 nonobese) were compared using the Eating Disorder Inventory (EDI). The three groups differed significantly on two (drive for thinness and body dissatisfaction) of the three eating-related scales and on all five of the general personality scales of the EDI. When age and depression level were controlled, findings for the eating-related scales did not change, whereas four of the five general personality scales were no longer significant. Post hoc analyses revealed that the BN group and the nonobese BED group had significantly higher drive for thinness than the obese BED group. The nonobese and the obese BED groups did not differ from each other in any area (other than drive for thinness), including body dissatisfaction. The nonobese and the obese BED groups had significantly lower maturity features than the BN group. Our findings suggest that when the effects of age and depression levels are controlled, treatment-seeking women with BN and BED are generally similar. Certain differences that do exist between women with BN and BED are associated with obesity status (drive for thinness), whereas others are associated with diagnosis (body dissatisfaction, maturity fears).     

Psychiatric comorbidity in a Brazilian sample of patients with binge-eating disorder

We compared sociodemographic characteristics and psychiatric status in obese Brazilian patients who did (n=32) and did not (n=33) meet DSM-IV criteria for binge-eating disorder (BED). The sample's mean age was 35.0 years (+/-10.5), with 92.3% of individuals being female and 41.5% having some higher education. Obese binge eaters (OBE) were significantly more likely than obese non-binge eaters to meet criteria for a current diagnosis of any axis I disorder, any mood disorder and any anxiety disorder. Specifically, OBE patients were characterized by significantly higher rates of current and lifetime histories of major depressive disorder. Similar to patients from developed countries, Brazilian patients with BED display increased rates of psychiatric comorbidity, particularly mood and anxiety disorders.     

Reliability and validity of the Japanese version of the World Health Organization-Five Well-Being Index in the context of detecting depression in diabetic patients

The present study had two aims. The first was to evaluate the reliability and the validity of the Japanese version of the World Health Organization (WHO)-Five Well-Being Index (WHO-5-J) as a brief well-being scale. The second was to examine the discriminatory validity of this test as a screening tool for current depressive episodes in diabetic patients. A sample of 129 diabetic patients completed the WHO-5-J. Of these, 65 were also interviewed by psychiatrists to assess whether they had any current depressive episodes according to DSM-IV. The internal consistency was evaluated using Cronbach's alpha, the Loevinger coefficient of homogeneity, and factor analysis. The external concurrent validity was evaluated by correlations with the external scales potentially related to subjective well-being. Discriminatory validity was evaluated using receiver operating characteristic (ROC) analysis. Cronbach's alpha and the Loevinger coefficient were estimated to be 0.89 and 0.65, respectively. A factor analysis identified only one factor. The WHO-5-J was significantly correlated with a number of major diabetic complications, depression, anxiety, and subjective quality of life. ROC analysis showed that the WHO-5-J can be used to detect a current depressive episode (area under curve: 0.92; 95% confidence interval: 0.85-0.98). A cut-off of <13 yielded the best sensitivity/specificity trade-off: sensitivity, 100%; specificity, 78%. The WHO-5-J was thus found to have a sufficient reliability and validity, indicating that it is a useful instrument for detecting current depressive episodes in diabetic patients.     

Relation of factor-analyzed symptom dimensions of obsessive-compulsive disorder to personality disorders

OBJECTIVE: To assess the relation between symptom dimensions of obsessive-compulsive disorder (OCD) and comorbid personality disorders (PDs). METHOD: The scores of 75 OCD outpatients on five previously identified symptom dimensions were entered into multiple regression models as predictors of: 1) the presence of any type of PD; 2) the number of PDs; 3) the presence of any cluster A, B or C PD; and 4) the presence of each individual PD. RESULTS: Twenty-eight patients (37.3%) met criteria for one or more PDs. High scores on the 'Hoarding' dimension were strongly related to the presence of any Axis II diagnosis, and to the number of PDs. Cluster C PDs (especially obsessive-compulsive and avoidant) had the highest partial correlations with 'Hoarding'. These results were independent of OCD symptom severity. CONCLUSION: Previous conflicting findings about the prevalence of certain PDs in OCD might be due in part to differences in the constitution of the particular patient groups studied.     

Validation of the WHO Quality of Life assessment instrument (WHOQOL-100) in a population of Dutch adult psychiatric outpatients.

BACKGROUND: Research concerning the psychometric properties of the WHO Quality of Life Assessment Instrument (WHOQOL-100) in general populations of psychiatric outpatients has not been performed systematically. AIMS: To examine the content validity, construct validity, and reliability of the WHOQOL-100 in a general population of Dutch adult psychiatric outpatients. METHOD: A total of 533 psychiatric outpatients entered the study (438 randomly selected, 85 internally referred). Participants completed self-administered questionnaires for measuring quality of life (WHOQOL-100), psychopathological symptoms (SCL-90), and perceived social support (PSSS). In addition, they underwent two semi-structured interviews in order to obtain Axis-I and Axis-II diagnoses, according to DSM-IV. RESULTS: The drop-out percentage was low (7.1%). Of the 24 facets of the WHOQOL-100, 22 had a good distribution of scores, leaving out the facets physical environment and transport. Exploratory factor analysis revealed a four-factor structure, which was similar to earlier findings in patients with specific somatic diseases and depressive disorders. Various-a priori expected-positive and negative correlations were found between facets and domains of the WHOQOL-100, and dimensions of the SCL-90 and the PSSS-score, indicating good construct validity of the WHOQOL-100. The internal consistency of all facets and the four domains of the WHOQOL-100 was good (Cronbach's alpha's ranging from 0.62 to 0.93 and 0.64 to 0.84, respectively). Sparse and relatively low correlations were found between demographic characteristics (age and sex) and WHOQOL-100 scores. CONCLUSIONS: Content validity, construct validity, and reliability of the WHOQOL-100 in a population of adult Dutch psychiatric outpatients are good. The WHOQOL-100 appears to be a suitable instrument for measuring quality of life in adult psychiatric outpatients.     

The prevalence of atypical features across mood,anxiety, and personality disorders

This study examines and compares the prevalence rates of the atypical features subtype across each of the major mood, anxiety, and personality disorders (PDs). It also evaluates the impact that comorbid anxiety and PDs have on the likelihood that depressed patients will present with atypical symptoms. Eleven hundred thirty psychiatric outpatients were evaluated for the presence of atypical symptoms. All axis I diagnoses were made using the Structured Clinical Interview for DSM-IV (SCID). PDs were assessed in a subset of 530 patients using the Structured Interview for DSM-IV Personality Disorders (SIDP-IV). From a sample of 579 patients diagnosed with a current major depressive disorder, 22.5% met criteria for the atypical subtype. Prevalence rates were similar in bipolar and unipolar patients, although the pattern of symptoms was distinct. Prevalence rates were lower in patients with dysthymic disorder (12.5%), adjustment disorder with depressed mood (9.4%), and depression not otherwise specified (NOS) (7.9%). When major depression existed in the presence of a comorbid anxiety disorder, the likelihood of presenting with atypical features doubled. Nine percent of the patients diagnosed with an anxiety disorder (without a comorbid depressive disorder) met criteria for atypical features. Two of the four atypical symptoms, leaden paralysis and rejection sensitivity, were found to be especially prominent in nondepressed anxiety disorder patients. Of the 10 PDs listed in DSM-IV, only avoidant PD was associated with the atypical features subtype. In large part, this was accounted for by the high rate of rejection sensitivity in these patients. In conclusion, as many as one quarter of depressed patients who present for outpatient psychiatric treatment meet criteria for the atypical features subtype. There appears to be a strong association between anxiety and atypical depression, but the exact nature of this relationship needs to be further elucidated. It is unclear whether personality pathology is independently associated with the atypical features subtype.     

Prevalence of personality disorders using two diagnostic systems in psychiatric outpatients in Shanghai, China: a comparison of uni-axial and multi-axial formulation

Objective

To compare multi-axial (DSM-IV) with uni-axial diagnostic system (CCMD-3, Chinese Classification and Diagnostic Criteria of Mental Disorders) as diagnostic methods to determine the prevalence of personality disorders (PDs) in Chinese psychiatric outpatients.

Method

3,075 outpatients were randomly sampled from clinical settings in China. CCMD-3 PDs were evaluated as per routine psychiatric practice. DSM-IV PDs were assessed using both self-reported questionnaire and structured clinical interview.

Results

The prevalence estimate for any type of PD in the total sample is 31.93% as reflected in the DSM-IV. This figure is nearly 110 times as large as the prevalence estimate for the CCMD-3. Only 9 outpatients were diagnosed with PD based on the CCMD-3. Amongst the 10 forms of DSM-IV PDs, avoidant (8.1%), obsessive–compulsive (7.6%), paranoid (6.0%), and borderline (5.8%) PDs were the most prevalent subtypes. This study found that PDs are commonly associated with the following: (i) the younger aged; (ii) single marital status; (iii) those who were not raised by their parents; (iv) introverted personalities; (v) first-time seekers of psycho-counseling treatment; and (vi) patients with co-morbid mood or anxiety disorders.

Conclusions

PDs are easily overlooked when the diagnosis is made based on the CCMD-3 uni-axial diagnostic system. However, it was found that personality pathology is common in the Chinese psychiatric community when using the DSM-IV classification system. Existing evidence suggest, at least indirectly, that there are important benefits of moving towards a multi-axial diagnostic approach in psychiatric practice.