An evaluation of DSM-III-R personality disorders.

This study evaluated the extent to which the features of personality disorders are organized into the 11 diagnoses proposed by DSM-III-R. The traits composing personality disorder diagnoses were identified in earlier studies. Seventy-nine traits were required to represent personality diagnoses. Self-report scales were developed to measure each trait. The factorial structure underlying the trait scales was examined in a sample of 158 patients with a primary diagnosis of personality disorder and a sample of 274 general population subjects. Eleven principal components were extracted from each data set and were rotated to the same oblique criterion. The decision to extract 11 components was based on a priori expectations derived from DSM-III-R. Factor comparability coefficients were computed to quantify the similarity of the 2 solutions. A high degree of similarity was observed between the factor structure in the clinical and general population samples, suggesting that features of personality pathology are continuous dimensions. Although a number of factors demonstrated a degree of resemblance to some DSM-III-R diagnostic categories, the overall correspondence was not strong. A second-order factor analysis failed to reproduce the 3 Axis II diagnostic clusters. The results do not support the categorical model used in DSM-III-R and they provide only limited support for DSM-III-R diagnostic concepts.     

Repetition of parasuicide —ICD-10 personality disorders and adversity

Patients with a history of previous parasuicide were compared to those who had made their first attempt. A scale for suicidal ideation derived from the Scaled Version of the General Health Questionnaire was completed by patients. ICD-10 personality disorder diagnoses were derived from the Standardized Assessment of Personality which was administered to knowledgeable informants. Logistic regression showed that unemployment, increasing severity of suicidal ideation, previous psychiatric treatment and borderline personality disorder increased the risk of reports of previous parasuicide. Anankastic personality disorder decreased the risk of reports of previous parasuicide. Unemployment and specific personality disorders have independent risks for repetition of parasuicide. Specific ICD-10 personality disorders may increase or decrease the risk for repetition of parasuicide.     

Naturalistic study on ICD-10 personality disorders

Objective. To study the frequency, socio-demography and comorbidity of ICD-10 personality disorders (PD), especially of emotionally unstable PD, in psychiatric inpatients. To test the subdivision of emotionally unstable PD in impulsive and borderline subtypes. Methods. Data on all psychiatric hospital stays in the Canton of Zurich in the years 1998–2002, routinely collected at the time of each patient's hospitalization, were analysed. Results. PD was diagnosed in 10.2% of all inpatients, and the proportion of emotionally unstable PD diagnosis was 54.5%. There are considerable differences between impulsive and borderline personality disorders with respect to sex, age, employment status and comorbidity. Conclusion. Emotionally unstable PD is the most frequent PD in clinical settings. Its differentiation into impulsive and borderline subtypes is justified.     

Factor structure of DSM-III-R personality disorders shown by self-report questionnaire: implications for classifying and assessing personality disorders.

A modified version of the revised Personality Diagnostic Questionnaire (PDQ-R), based on DSM-III-R personality disorders (PD), was completed by 74 psychiatric patients. A factor analysis of the scores for each of the PD (i.e. of the number of positive DSM-III-R criteria for each of the PD) yielded 3 factors that defined 3 PD clusters. These were similar to the 3 DMS-III-R PD clusters for 7 of the 11 PD categories. The 3-group solution of a cluster analysis of the patients (using their scores of positive criteria for each of the PD) did not reflect these factors; the main discriminating variable between the 3 groups of patients was the total number of positive PD criteria. It is suggested that, for the routine assessment of patients, the most important derivative of the DSM-III-R classification of PD is the total score of positive PD criteria.     

Development and validation of a computerized screening test for personality disorders in DSM-III-R

The available self-report instruments designed to measure personality disorder (PD) are time-consuming to administer and/or score and can be impractical for routine clinical use. There is a need for a computerized method of personality assessment based on contemporary systems of classification. A computerized DSM-III-R-based questionnaire was developed and validated against the structured clinical interview for DSM-III-R Axis-II disorders on a sample of 60 subjects. The computerized test showed moderate validity as a diagnostic instrument (mean kappa coefficient=0.47). With adjusted cut-off scores it was valid as a screening instrument (mean sensitivity=0.87). Antisocial, borderline and avoidant PD scores were strongly correlated across measures and not subject to significant observer bias.     

Contextual aspects of mental disorders: a proposal for axis III of the ICD-10 multiaxial system

After several years of development and testing, the World Health Organization (WHO) has recently completed work on the multiaxial presentation of ICD-10 for use in adult psychiatry. Axis III of the ICD-10 multiaxial system is intended for clinicians’ reporting of contextual factors which may influence the diagnosis, treatment or prognosis of mental disorders that are recorded on Axis I. It was tested in two WHO-coordinated international field trials and found to be user-friendly, reasonably reliable and useful in routine clinical work, in the training of mental health professionals and in research on mental disorders.     

Dimensional characteristics of DSM-IV personality disorders in a large epidemiological sample

OBJECTIVE: To assess the five-factor model (FFM) characteristics of young adults with Diagnostic Statistical Manual-IV (DSM-IV) personality disorders in a large community study. METHOD: As part of the eighth wave of a cohort study, 1469 young adults (mean age: 24 years) completed the NEO-five factor inventory, 1145 of whom also had an informant-based personality disorder assessment. RESULTS: The prevalence of personality disorder was 18.6% (95% CI: 16.5-20.7). There were consistent positive associations with neuroticism and negative associations with agreeableness across all three clusters of personality disorder. CONCLUSION: In young adults, high neuroticism and low agreeableness are consistent dimensional characteristics of all personality disorder clusters.     

Commentary: Commentary on the Twitter comments evoked by the May 2022 debate on diagnosing personality disorders in adolescents

The debate about the value and utility of personality disorder (PD) diagnosis in adolescence published in the May 2022 issue of CAMH generated fervent Twitter discussion. This commentary addresses some points raised in the Twitter discussion that represent important social and/or cultural beliefs that are often presented in day-to-day practice but are rarely tested in the context of scientific evidence. This includes, in particular, the assertion that symptoms used to diagnose personality disorder are better described as sequelae of trauma, and the assertion that effective treatment for PD is possible without a diagnosis. The call for a fundamental transformation of mental health services that currently do not meet the needs of people with PD and for the involvement of people with lived experience as equal partner in this process is supported by evidence and might represent common ground among those clinician-scientist advocating for early intervention for PD and those expressing their concerns about this issue.     

Bipolar obsessive-compulsive disorder and personality disorders

OBJECTIVES: Relatively few systematic data exist on the clinical impact of bipolar comorbidity in obsessive-compulsive disorder (OCD) and no studies have investigated the influence of such a comorbidity on the prevalence and pattern of Axis II comorbidity. The aim of the present study was to explore the comorbidity of personality disorders in a group of patients with OCD and comorbid bipolar disorder (BD). METHODS: The sample consisted of 204 subjects with a principal diagnosis of OCD (DSM-IV) and a Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) score>or=16 recruited from all patients consecutively referred to the Anxiety and Mood Disorders Unit, Department of Neuroscience, University of Turin over a period of 5 years (January 1998-December 2002). Diagnostic evaluation and Axis I comorbidities were collected by means of the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). Personality status was assessed by using the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II). Socio-demographic and clinical features (including Axis II comorbidities) were compared between OCD patients with and without a lifetime comorbidity of BD. RESULTS: A total of 21 patients with OCD (10.3%) met DSM-IV criteria for a lifetime BD diagnosis: 4 (2.0%) with BD type I and 17 (8.3%) with BD type II. Those without a BD diagnosis showed significantly higher rates of male gender, sexual and hoarding obsessions, repeating compulsions and lifetime comorbid substance use disorders, when compared with patients with BD/OCD. With regard to personality disorders, those with BD/OCD showed higher prevalence rates of Cluster A (42.9% versus 21.3%; p=0.027) and Cluster B (57.1% versus 29.0%; p=0.009) personality disorders. Narcissistic and antisocial personality disorders were more frequent in BD/OCD. CONCLUSIONS: Our results point towards clinically relevant effects of comorbid BD on the personality profiles of OCD patients, with higher rates of narcissistic and antisocial personality disorders in BD/OCD patients.     

Cumulative prevalence of personality disorders between adolescence and adulthood

Objective: To investigate the cumulative prevalence of personality disorder (PD) among adults in the community, based on prospective longitudinal data from a series of psychiatric interviews. Method: Psychiatric interviews were administered to a regionally representative community‐based sample of 568 individuals in 1983 (mean age = 14), 1985–1986 (mean age = 16), 1991–1993 (mean age = 22), and 2001–2004 (mean age 33). Results: The point prevalence of any current DSM‐IV PD, including depressive PD and passive‐aggressive PD, varied between 12.7% and 14.6% across the four diagnostic assessments. The cumulative prevalence of PD increased at each of the follow‐up assessments. At mean age 33, the estimated lifetime prevalence of PD was 28.2%. Conclusion: The cumulative prevalence of PD, based on a series of interviews conducted during adolescence and adulthood, may be substantially higher than the point prevalence of current PD based on a single assessment interview.     

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.     

Classification of frequency distributions of diagnostic criteria scores in twelve personality disorders by the curve fitting method

The purpose of the present study was to investigate whether each personality disorder (PD) has a different frequency distribution of diagnostic criteria, and to classify the distribution of each PD on the basis of shape by the curve fitting method. A total of 4740 male subjects in early adulthood completed the Korean version of the Personality Diagnostic Questionnaire (4th revision; PDQ-4+). The frequency distribution of scores in each PD was specified to the best fitted model by the curve estimation procedure. Twelve distributions of PD criteria were fitted to three types of curve models (quadratic, cubic, and logistic). The quadratic model included obsessive-compulsive and histrionic PD. The cubic model included borderline, narcissistic, avoidant, passive-aggressive, paranoid, and schizotypal PD. The logistic model contained dependent, depressive, schizoid, and antisocial PD. The results suggest that each PD has a different type of distribution and each distribution of PD might be classified to a specific curve model. Also, the results suggest that the issue of continuities between PD and the normal group could not be generalized to all PD, but should be considered individually for each PD.     

Possible correlates of DSM-III-R personality disorders

An association between personality disorder (PD) pathology, including symptoms of all PD types and Axis I disorders, and suicidal behaviour was studied in a series of 90 non-schizophrenic, non-bipolar in-patients of both sexes without mental retardation or organic brain syndrome. All of these patients, who scored positively on the SCID-II-PQ, were interviewed with the PDE and SCID-P, and with the Structured interview for the study of childhood trauma provided with supplementary items reflecting suicidal behaviour. Mood disorders were found to be significantly correlated with cluster C pathology (PD pathology always being expressed by dimensional PDE scores) and eating disorders were significantly correlated with cluster B pathology in women. Psychoactive substance use disorders were mainly correlated with cluster B pathology and anxiety disorders with cluster C pathology in both sexes. Suicidal behaviour was correlated with PD pathology of all clusters in women, but not in men. In women a strong correlation was found between suicidal behaviour and history of childhood trauma, especially sexual abuse. The results of this study indicate that there is some specificity with regard to the Axis I/Axis II association, more so in relation to PD clusters than in relation to the individual PD types. However, the relationships between PD pathology and Axis I disorders and suicidal behaviour are complex, and they differ between the sexes.     

Possible antecedents of DSM-III-R personality disorders

In order to extend our knowledge of the effects of environmental influences upon personality disorder (PD) pathology, childhood traumatic events and parental bonding were studied in 90 PD in-patients of both sexes. Childhood traumatic experiences (primarily physical and/or sexual abuse) and parental bonding dimensions were correlated with PD pathology depending on PD type and cluster. Important differences were found between the sexes. The quality of the paternal relationship (high control, low care) was significantly associated with PD pathology in men, whereas childhood traumatic experiences and the quality of maternal parenting were associated with PD pathology in women. The study of traumatic events such as childhood abuse has recently been the focus of considerable attention. More emphasis in empirical research needs to be given to parental relationships, especially in the case of men.     

Severity of personality disorders and suicide attempt

Objective: Severity of personality disorders (PDs) may be more useful in estimating suicide risk than the diagnosis of specific PDs. We hypothesized that suicide attempters with severe PD would present more attempts and attempts of greater severity/lethality. Method: Four hundred and forty‐six suicide attempters were assessed. PD diagnosis was made using the International Personality Disorder Questionnaire – Screening Questionnaire. PDs were classified using Tyrer and Johnson’s classification of severity (no PD, simple PD, diffuse PD). Severity/lethality of attempts was measured with the Suicide Intent Scale, Risk‐Rescue Rating Scale and Lethality Rating Scale. Results: Attempters with severe (diffuse) PD had more attempts than the other groups. After controlling for age and gender, this difference remained significant only for the younger age group and women. There was no relationship between severity of PDs and severity/lethality of attempts. Conclusion: Younger female attempters with severe PD are prone to repeated attempts. However, the severity of PD was not related to the severity/lethality of suicide attempts.     

强迫型人格障碍与其他精神障碍的关系

强迫型人格障碍（OCPD）是指一种专注于追求秩序、完美以及精神和人际关系的控制,因而失去灵活性、开放性和效率的普遍模式.由于OCPD与其他精神障碍有很高的共病率,且它们之间的关系向来存在争议,因此现着重对已有相关研究进行归纳总结,以期为未来研究提供方向和建议.     

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.     

Comorbidity between obsessive-compulsive disorder (OCD) and personality disorders

The aims of the present study were to examine the frequency of personality disorders in 36 patients with obsessive-compulsive disorder (OCD), and to investigate whether patients with a coexisting personality disorder could be characterized by certain personality traits assessed by means of the Karolinska Scales of Personality (KSP). In total, 27 (75%) of the OCD patients fulfilled the DSM-III-R criteria for a personality disorder, and 13 patients (36%) had an obsessive-compulsive personality disorder. Subjects with a comorbid personality disorder had significantly higher scores on most of the KSP scales, including all anxiety scales, as well as scales measuring indirect aggression, irritability, guilt and detachment, whereas subjects without personality disorders did not differ significantly from healthy controls with regard to personality traits.     

Personality,personality disorders,and the process of change

Objective: The present paper elaborates a process perspective of change in psychotherapy for personality disorders (PDs). Firstly, the paper reviews the literature of mechanisms of change in treatments of PD, with the main focus on emotional processing and socio-cognitive processing. Secondly, it proposes an illustrative case-series analysis of eight cases, drawn from a mediation analysis conducted within the context of a randomized controlled trial for borderline personality disorder (BPD). Method: As such, cases with good and poor outcomes are compared, as are cases with poor and good intake features and cases with poor and good process markers across treatment. Results: The results illustrate possible pathways to healthy change over the course of four months of treatment, and possible pathways of the absence of change. Conclusions: These results are discussed with regard to three main research perspectives: the combination of qualitative and quantitative methodology in psychotherapy research may be applied to case study research, a neurobehavioral perspective on change may incorporate the individualized experience in the laboratory and therapist responsiveness to patient characteristics may be a core feature of fostering change.

Clinical or methodological significance of this article: The present paper illustrates individual pathways to change in personality disorders. It illustrates how coping capacities influence the process of psychotherapy and outcome in personality disorders. It demonstrates the relevance of individualizing treatments for personality disorders. It demonstrates several integrative features of psychotherapy research, in particular the use of neurobehavioral paradigms and the integration of single-case research within randomized controlled trials.