Temperament profiles in personality disorders among a young adult population

The objective of this study was to describe the temperament dimension profiles assessed by the Temperament and Character Inventory (TCI) among young adults with the DSM-III-R personality disorder (PD). Our hypothesis was that PD clusters and separate PDs can be distinguished from one another by their specific temperament profiles. As a part of the 31-year follow-up survey of the prospective Northern Finland 1966 Birth Cohort, the cohort members living in the city of Oulu at the age of 31 years (n=1609) were invited to participate in a two-phase field study. The Structured Clinical Interview for DSM-III-R for PDs (SCID-II) was used as diagnostic instrument. The final study sample consisted of the 1311 subjects who had completed the Hopkins Symptom Check List-25 questionnaire for screening and had given a written informed consent. Of the 321 SCID interviewed subjects, 74 met the criteria for at least one PD and had completed the TCI. The mean TCI scores of subjects with PD and control subjects without PD (n=910) were compared. Low Novelty Seeking, high Harm Avoidance and low Reward Dependence characterized cluster A and C PDs. Subjects with a cluster B PD did not differ from controls, except for Novelty Seeking, which was high. The temperament dimensions could not distinguish different PDs very well, with the only exception of persons with obsessive-compulsive PD. PD clusters were associated with different profiles of temperament, lending some support for Cloninger's typology.     

Childhood family structure and personality disorders in adulthood.

BACKGROUND: The association between childhood family structure and sociodemographic characteristics and personality disorders (PDs) in a general population sample was studied. METHODS: This study is a substudy of the prospective Northern Finland 1966 Birth Cohort Project with 1588 young adult subjects. The case-finding methods according to the DSM-III-R criteria for PDs were: (1) Structured Clinical Interview for DSM-III-R (SCID) for 321 cases who participated in a 2-phase field study, (2) Finnish Hospital Discharge Register data, and (3) analysis of the patient records in public outpatient care in 1982-1997. Statistical analyses were performed on the association between PDs and family background factors. RESULTS: Altogether 110 (7.0%) of the subjects had at least one probable or definite PD. After adjusting for confounders (gender, parental social class and parental psychiatric disorder) the results indicated that single-parent family type in childhood was associated with cluster B PDs in adulthood. Being an only child in childhood was associated with cluster A PDs. No special childhood risk factors were found for cluster C PDs. CONCLUSIONS: Results suggest that single-parent family type at birth and being an only child in the 1960s are associated with PD in adulthood. Further studies are needed to explore the psychosocial aspects of family environment which may nowadays promote vulnerability to PDs in adulthood.     

Temperament profiles in personality disorders among a young adult population

The objective of this study was to describe the temperament dimension profiles assessed by the Temperament and Character Inventory (TCI) among young adults with the DSM-III-R personality disorder (PD). Our hypothesis was that PD clusters and separate PDs can be distinguished from one another by their specific temperament profiles. As a part of the 31-year follow-up survey of the prospective Northern Finland 1966 Birth Cohort, the cohort members living in the city of Oulu at the age of 31 years (n=1609) were invited to participate in a two-phase field study. The Structured Clinical Interview for DSM-III-R for PDs (SCID–II) was used as diagnostic instrument. The final study sample consisted of the 1311 subjects who had completed the Hopkins Symptom Check List-25 questionnaire for screening and had given a written informed consent. Of the 321 SCID interviewed subjects, 74 met the criteria for at least one PD and had completed the TCI. The mean TCI scores of subjects with PD and control subjects without PD (n=910) were compared. Low Novelty Seeking, high Harm Avoidance and low Reward Dependence characterized cluster A and C PDs. Subjects with a cluster B PD did not differ from controls, except for Novelty Seeking, which was high. The temperament dimensions could not distinguish different PDs very well, with the only exception of persons with obsessive–compulsive PD. PD clusters were associated with different profiles of temperament, lending some support for Cloninger's typology.     

Associations of past conduct disorder with personality disorders in 'non-psychotic' psychiatric inpatients.

The aim was to investigate associations of a history of features of DSM-III-R conduct disorder (CD) with features of DSM-III-R personality disorders (PDs) and psychopathy, in inpatient psychiatric practice. Fifty-six psychiatric inpatients, without a history of specified 'psychoses', were assessed by the SCID structured interview for DSM-III-R PDs and the 'Psychopathy Checklist Revised' (PCL-R). In a sample in which 59% had borderline PD, significant associations between a history of CD criteria and the adult features of antisocial PD (APD) were relatively specific compared with other PDs, but were weaker in women. However, significant correlations between the number of positive CD criteria and PCL-R scores were similar in both genders. The relatively specific associations between CD and adult features of APD are likely to be relevant to psychiatric patients who show various presentations of PD, if these include some adult features of APD. The findings inform the understanding of the development and classification of PDs.     

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.     

Patterns of comorbidity among DSM-III-R personality disorders

The aim of this study was to examine patterns of comorbidity among personality disorders (PDs) in a sample of 156 psychiatric inpatients. PDs were assessed with Semistructured Clinical Interview for DSM-III-R Personality Disorders. To determine significant co-occurrence among axis II diagnoses, odds ratio and the percent of co-occurrence of pairs of disorders were calculated. Both statistical methods revealed high rates of comorbidity: significance association was found for 36 pairs of disorders using the percent of co-occurrence, and for 22 pairs of disorders using the odds ratio. These results support the concept of 'apparent comorbidity' for most PDs, deriving from conceptual and definitional artifacts or from a 'state-biasing effect'. In light of these observations, a categorical approach to PDs, resulting in a list of diagnoses, appears useless in psychiatric practice. A dimensional classification is probably better suited for PDs, improving the understanding of personality psychopathology and its clinical implications.     

DSM-III-R self-defeating personality disorder criteria evaluated by patients' self-report questionnaire: relationships with other personality disorders and positive predictive powers of the individual criteria

A self-report questionnaire for DSM-III-R personality disorders (PDs) was completed by 64 patients in adult psychiatric practice and their informants. Various correlations and associations of the number of patients’ positive criteria (scores) for the controversial category of self-defeating PD (SDPD) are reported. When evaluated by a patient's self-report, the highest correlations of SDPD scores were with borderline PD in relation to individual PDs, and cluster C in relation to the 3 DSM-III-R PD clusters. Criteria 2 and 7 had positive predictive powers of 0.75 and 0.67 for membership of the subgroup based on scores of 5 or more positive criteria for SDPD. Positive ratings for criterion 5, involving anhedonia, were significantly associated with informants’ ratings. SDPD features appear to be present in many psychiatric patients with PD and should be evaluated in PD assessment.     

Consequences of comorbid personality disorders in major depression

To describe consequences of the presence of a comorbid personality disorder (PD) in inpatients with a major depressive disorder (MDD) on variables connected to course and outcome of the unipolar affective illness, 117 inpatients with a major depressive episode were assessed at various times during inpatient treatment. Trait markers (including personality and PDs) were obtained toward the end of the treatment, when acute psychopathology had largely remitted. Fifty-one percent of all patients fulfilled the criteria for a DSM-III-R PD, 15% met the criteria for two or more PDs, and 18% fulfilled the criteria for at least one cluster A or B PD. Except for age of onset, number of suicide attempts and quality of life all other outcome and course variables were unrelated to the presence or absence of a comorbid PD. In this sample, one comorbid PD in patients with MDD was of limited relevance to the course of the affective illness, especially if it was a cluster C PD. Two or more comorbid PDs in patients with unipolar depression tended to reduce quality of life and have an earlier age of onset. Patients with cluster A or B PD and MDD had attempted suicide more often than patients with a cluster C PD and MDD. Although comorbid cluster C PDs were seen in all age groups of patients with an MDD, cluster A or B PDs and the presence of more than one PD were mainly seen in younger patients with an MDD.     

Identifying personality disorders: towards the development of a clinical screening instrument

The study objective was to identify a set of personality disorder (PD) criteria from the DSM PD diagnostic sets that can be used to detect subjects with an increased likelihood of having a PD diagnosis. In a series of outpatients evaluated systematically in two waves for every criteria item for 12 DSM-III-R PDs, stepwise logistic regression identified 45 criteria as discriminative for their specific PDs, which are selected for further analysis to assess their ability to discriminate for any PD. Receiver operating characteristic (ROC) analysis is used to evaluate their discriminative power in an independent conjoined sample (N = 1,342) from six centers that assessed every PD criteria item by structured instrument (Structured Clinical Interview for DSM-III-R PDs [SCID-II, Personality Disorder Examination [PDE], and Structured Interview for DSM-III-R PDs [SIDP-R]). The cutoff that maximizes information gain is used to determine the diagnostic threshold (DT). Initially, 15 of 45 criteria are identified. At the 0.43 PD prevalence, a DT of 2 or more of the 15 PD criteria across samples is optimal. The maximum information gain (MIG) is .42 bits, and the AUR is 0.94+/-.007. Other performance indices at this cutoff are .90 sensitivity, .84 specificity, .81 positive predictive power (PPP), .91 negative predictive power (NPP), and .86 hit rate (HR). Taken collectively, the 15 PD criteria selected by the data reduction techniques suggest a narrowed set to be assessed in screening for the presence or absence of any PD with comparable or better psychometric properties than other tests routinely used for diagnosing medical and psychiatric disorders. If specific PD categorization is needed, a second-step comprehensive assessment should follow.     

A comparison of gains after treatment at a psychiatric outpatient clinic in patients with cluster A + B, or cluster C personality disorders, and non-psychotic axis I disorders

Few studies exist on the outcome of patients with personality disorders (PDs) treated at ordinary outpatient clinics. This study examines the gains of such patients 2 years after treatment start at an outpatient clinic. Three patient groups were sampled: cluster A + B PDs, cluster C PDs and axis I disorders. Fifty-eight patients (53%) were amenable to follow-up, and they did not show less psychopathology than the non-compliers. All patients had structured interviews and filled in questionnaires. Patients in the PDs cluster A + B group showed considerable gains, while that was not found for the PDs cluster C and Axis I disorder groups. Since almost all patients received long-term psychotherapy sometimes combined with antidepressant drugs, the finding that such a treatment mainly shows gains in more severely disturbed PDs patients should be replicated in larger samples at ordinary psychiatric outpatient clinics.     

A comparison of gains after treatment at a psychiatric outpatient clinic in patients with cluster A+B,or cluster C personality disorders,and non-psychotic axis I disorders

Few studies exist on the outcome of patients with personality disorders (PDs) treated at ordinary outpatient clinics. This study examines the gains of such patients 2?years after treatment start at an outpatient clinic. Three patient groups were sampled: cluster A?+?B PDs, cluster C PDs and axis I disorders. Fifty-eight patients (53%) were amenable to follow-up, and they did not show less psychopathology than the non-compliers. All patients had structured interviews and filled in questionnaires. Patients in the PDs cluster A?+?B group showed considerable gains, while that was not found for the PDs cluster C and Axis I disorder groups. Since almost all patients received long-term psychotherapy sometimes combined with antidepressant drugs, the finding that such a treatment mainly shows gains in more severely disturbed PDs patients should be replicated in larger samples at ordinary psychiatric outpatient clinics.     

Patterns of covariation of DSM-IV personality disorders in a mixed psychiatric sample

The covariation patterns of DSM-IV personality disorders (PDs) were studied in 431 consecutively admitted psychiatric patients. The co-occurrence rate was greater than 50% for all DSM-IV PDs. Both bivariate association tests and loglinear models showed distinct significant covariation patterns among PDs which were stable across confounder strata. DSM-IV PD clusters were not replicated, with the exception of cluster A. Principal-component analysis (PCA) showed the presence of 3 latent dimensions, thus explaining the DSM-IV PD covariation patterns. These results seem to stress the inadequacy of the DSM-IV categorical model of PD assessment. The need for a reduction of axis II categories and the inclusion of a dimensional model in the diagnostic assessment of DSM-IV PDs are discussed.     

Role of childhood traumatic experience in personality disorders in China

BackgroundThere has been no large-scale examination of the association between types of childhood abuse and personality disorders (PDs) in China using standardized assessment tools and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria. Hence, this study aimed to explore the relationship between retrospective reports of various types of childhood maltreatments and current DSM-IV PDs in a clinical population in China, Shanghai.MethodOne thousand four hundred two subjects were randomly sampled from the Shanghai Psychological Counselling Centre. PDs were assessed using the Personality Diagnostic Questionnaire, Fourth Edition Plus. Participants were also interviewed using the Structured Clinical Interview for DSM-IV axis II. The Child Trauma Questionnaire (CTQ) was used to assess childhood maltreatment in 5 domains (emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect).ResultsAccording to Pearson correlations, childhood maltreatment had a strong association with most PDs. Subsequently, using partial correlations, significant relationships were also demonstrated between cluster B PDs and all the traumatic factors except physical neglect. A strongest positive correlation was found between cluster B PD and CTQ total scores (r = .312, P < .01). Using the Kruskal-Wallis rank sum test, significant differences in 4 groups of subjects (clusters A, B, and C PD and non-PD) in terms of emotional abuse (χ² = 34.864, P < .01), physical abuse (χ² = 14.996, P < .05), sex abuse (χ² = 9.211, P < .05), and emotional neglect (χ² = 17.987, P < .01) were found. Stepwise regression analysis indicated that emotional abuse and emotional neglect were predictive for clusters A and B PD, and sexual abuse was highly predictive for cluster B PD; only emotional neglect was predictive for cluster C PD.ConclusionEarly traumatic experiences are strongly related to the development of PDs. The effects of childhood maltreatment in the 3 clusters of PDs are different. Childhood trauma has the most significant impact on cluster B PD.     

The prevalence of personality disorders in a community sample

BACKGROUND: To our knowledge, no previous studies of personality disorders (PDs) in a large representative sample of the common population have been conducted. METHODS: A representative sample of 2053 individuals between the ages of 18 and 65 years in Oslo, the capital of Norway, was studied from 1994 to 1997. Information about PDs was obtained by means of the Structured Interview for DSM-III-R Personality Disorders, in conjunction with an interview recording demographic data. The subjects were interviewed primarily at home, but in some instances, also at the clinic. RESULTS: The prevalence of PDs was 13.4% (SE, 0.7). The prevalence rates (SEs) for specific PDs, irrespective of whether a person had 1 or more PD, were: paranoid, 2.4% (0.3); schizoid, 1.7% (1.6); schizotypal, 0.6% (0.2); antisocial, 0.7% (0.2); sadistic, 0.2% (0.1); borderline, 0.7% (0.2); histrionic, 2.0% (0.3); narcissistic, 0.8; (0.2); avoidant, 5.0% (0.5); dependent, 1.5% (0.3); obsessive-compulsive: 2.0% (0.3); passive-aggressive, 1.7% (0.3); self-defeating, 0.8%, (0.2). The prevalence of PDs was highest among subjects with only a high school education or less, and living without a partner in the center of the city. CONCLUSIONS: Personality disorders were found to be prevalent, with avoidant, schizoid, and paranoid PDs more common, and borderline PD less common than what is usually reported. Personality disorders tend to be more frequent among single individuals from the lower socioeconomic classes in the center of the city. It is impossible to determine what is cause and what is consequence from a cross-sectional study.     

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.     

Taxometric analyses of paranoid and schizoid personality disorders

There remains debate about whether personality disorders (PDs) are better conceptualized as categorical, reflecting discontinuity from normal personality; or dimensional, existing on a continuum of severity with normal personality traits. Evidence suggests that most PDs are dimensional but there is a lack of consensus about the structure of Cluster A disorders. Taxometric methods are adaptable to investigating the taxonic status of psychiatric disorders. The current study investigated the latent structure of paranoid and schizoid PDs in an epidemiological sample (N=43,093) drawn from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) using taxometric analyses. The current study used taxometric methods to analyze three indicators of paranoid PD - mistrust, resentment, and functional disturbance - and three indicators of schizoid PD - emotional detachment, social withdrawal, and functional disturbance - derived factor analytically. Overall, taxometrics supported a dimensional rather than taxonic structure for paranoid and schizoid PDs through examination of taxometric graphs and comparative curve fit indices. Dimensional models of paranoid and schizoid PDs better predicted social functioning, role-emotional, and mental health scales in the survey than categorical models. Evidence from the current study supports recent efforts to represent paranoid and schizoid PDs as well as other PDs along broad personality dimensions.     

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.     

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.     

Gender differences in social and interpersonal features and personality disorders among Japanese patients with obsessive-compulsive disorder

This study sought to elucidate the differential effect of gender on clinical features in 40 males and 54 females who met both DSM-III-R and DSM-IV criteria for obsessive-compulsive disorder (OCD). Males had a lower rate of marriage, and a higher rate of major impairment in social or occupational functioning, whereas females were significantly more likely to involve others in their OCD symptoms, such as reassurance-seeking. Although no significant differences were detected in the distribution of OCD symptoms, cluster A personality disorders (PDs), especially schizotypal PD, were more frequently diagnosed in males, and borderline and dependent PDs tended to be more prevalent in females. Thus, gender differences in OCD subjects were prominently observed in social or interpersonal features, which might be consistent with the differential PD pathology between males and females.     

The structure of personality disorders in DSM-III.

In DSM-III it is proposed that there are 11 personality disorders (PDs) that fall into 3 superordinate clusters: cluster A, labelled the odd or eccentric; cluster B, labelled the emotional, dramatic or erratic; and cluster C, described as the anxious or fearful. To check this proposal, data were obtained from a sample of 112 state hospital psychiatric inpatients via the Structured Interview for DSM-III Personality (SIDP). Various statistical techniques were applied to the data, ranging from the least constrained method of multidimensional scaling to the most constrained and statistically rigorous approach of confirmatory factor analysis. In the latter approach, the models suggested by the various statistical approaches were contrasted directly. A 3-cluster solution was accepted as the best representation of the data, although PD membership of the 3 clusters varied in some ways from those suggested by DSM-III. An exploratory correlation analysis showed that many of the items were more strongly correlated with PDs other than the ones specified by DSM-III, but generally items clustered within the 3 superordinate clusters. This issue deserves further investigation.