Confirmatory factor analysis of DSM-IV borderline,schizotypal, avoidant and obsessive-compulsive personality disorders: findings from the Collaborative Longitudinal Personality Disorders Study

OBJECTIVE: To test the diagnostic constructs implied by DSM-IV Axis-II personality disorders by examining relationships between different combinations of DSM-IV criteria. METHOD: Confirmatory factor analysis was used to test the borderline, schizotypal, avoidant and obsessive-compulsive personality disorder constructs in a large treatment-seeking sample (N= 668) from a multisite study. A model based on the three DSM-IV Axis II clusters was also tested. Both models were tested against a unitary 'generic' model constructed from four criteria sets combined. RESULTS: Goodness-of-fit for both the three-cluster and four disorder models was significantly better than the unidimensional model, and the four-disorder model was significantly better than the three-cluster model. Results were replicated using data from 2-year follow-up obtained by interviewers blind to original Axis II diagnoses at baseline. CONCLUSION: Support is provided for the DSM-IV disorder-level classification for schizotypal, borderline, avoidant and obsessive-compulsive personality disorders in a treatment-seeking sample.     

Short-term diagnostic stability of schizotypal,borderline, avoidant,and obsessive-compulsive personality disorders

OBJECTIVE: Personality disorders are defined as enduring patterns of maladaptive behaviors and traits that are stable over time. This study prospectively examined the stability of four personality disorders (schizotypal, borderline, avoidant, and obsessive-compulsive) over a 1-year follow-up period. METHOD: Subjects (N=668) were recruited from multiple clinical settings at four collaborating institutions. Subjects met criteria for one or more of the four personality disorders or were part of a comparison group of subjects with major depressive disorder and no personality disorder. Diagnoses were established by using semistructured interviews. Follow-up assessments, conducted 6 and 12 months after the baseline assessment, included monthly ratings of all criteria for the four personality disorders and weekly ratings of the course of major depressive disorder. The current report is based on 621 subjects with complete data through 12 months of the follow-up period. RESULTS: Significantly more subjects in each personality disorder group remained at diagnostic threshold throughout the 12 months of the follow-up period than did those in the major depressive disorder group. A continuous measure of number of criteria met was highly correlated across the three assessments. The majority of personality disorder subjects, however, did not consistently remain at diagnostic threshold, and the mean number of criteria met decreased significantly for each group. CONCLUSIONS: Individual differences in personality disorder features appear to be highly stable, although the number of criteria present decreases over time. Personality disorders may be characterized by stable trait constellations that fluctuate in degree of maladaptive expression.     

Functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder

OBJECTIVE: The purpose of this study was to compare psychosocial functioning in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder and patients with major depressive disorder and no personality disorder. METHOD: Patients (N=668) were recruited by the four clinical sites of the Collaborative Longitudinal Personality Disorders Study. The carefully diagnosed study groups were compared on an array of domains of psychosocial functioning, as measured by the Longitudinal Interval Follow-Up Evaluation--Baseline Version and the Social Adjustment Scale. RESULTS: Patients with schizotypal personality disorder and borderline personality disorder were found to have significantly more impairment at work, in social relationships, and at leisure than patients with obsessive-compulsive personality disorder or major depressive disorder; patients with avoidant personality disorder were intermediate. These differences were found across assessment modalities and remained significant after covarying for demographic differences and comorbid axis I psychopathology. CONCLUSIONS: Personality disorders are a significant source of psychiatric morbidity, accounting for more impairment in functioning than major depressive disorder alone.     

Treatment utilization by patients with personality disorders

OBJECTIVE: Utilization of mental health treatment was compared in patients with personality disorders and patients with major depressive disorder without personality disorder. METHOD: Semistructured interviews were used to assess diagnosis and treatment history of 664 patients in four representative personality disorder groups-schizotypal, borderline, avoidant, and obsessive-compulsive-and in a comparison group of patients with major depressive disorder. RESULTS: Patients with personality disorders had more extensive histories of psychiatric outpatient, inpatient, and psychopharmacologic treatment than patients with major depressive disorder. Compared to the depression group, patients with borderline personality disorder were significantly more likely to have received every type of psychosocial treatment except self-help groups, and patients with obsessive-compulsive personality disorder reported greater utilization of individual psychotherapy. Patients with borderline personality disorder were also more likely to have used antianxiety, antidepressant, and mood stabilizer medications, and those with borderline or schizotypal personality disorder had a greater likelihood of having received antipsychotic medications. Patients with borderline personality disorder had received greater amounts of treatment, except for family/couples therapy and self-help, than the depressed patients and patients with other personality disorders. CONCLUSIONS: These results underscore the importance of considering personality disorders in diagnosis and treatment of psychiatric patients. Borderline and schizotypal personality disorder are associated with extensive use of mental health resources, and other, less severe personality disorders may not be addressed sufficiently in treatment planning. More work is needed to determine whether patients with personality disorders are receiving adequate and appropriate mental health treatments.     

Personality disorders in patients with obsessive-compulsive disorder in Japan

A total of 75 patients with obsessive-compulsive disorder (OCD) were studied in order to investigate the characteristics of OCD symptoms and the comorbidity of personality disorders (PD). Contamination obsessions and checking compulsions were most commonly found in patients, of whom 53% met the criteria for at least one PD. Among comorbid PD, the anxious-fearful (cluster C) PDs, such as avoidant, obsessive-compulsive and dependent PD, were most prevalent, followed by the odd-eccentric (cluster A) PDs, such as paranoid and schizotypal PD. The patients with PD had more severe social maladaptation and concurrent depressive and anxious symptoms than the patients without any PD, despite the similar severity of OCD symptoms. These results are consistent with those reported in the Western world, and are considered to be relatively stable cross-culturally.     

Hierarchical relationships between borderline, schizotypal, avoidant and obsessive-compulsive personality disorders

OBJECTIVE: Comorbidity among personality disorders is widely considered problematic. The validity of one proposed solution, diagnostic hierarchies, was investigated in the current study with respect to borderline, schizotypal, avoidant, and obsessive-compulsive personality disorders. METHOD: One approach used discriminant functions, derived from multiple psycho-social domains, that were used to classify comorbid individuals from the Collaborative Longitudinal Personality Disorder study (CLPS) to explore the possibility of hierarchical precedence of one personality disorder over another. A second approach examined the incremental increase in R(2)-value in predicting functioning and personality provided by each diagnosis over each other diagnosis. RESULTS: Obsessive-compulsive personality disorder was consistently subordinate to other diagnoses, whereas other indications of hierarchical relationships were domain-specific. CONCLUSION: Results indicate minimal support for an over-arching hierarchical pattern among studied personality disorders, and suggest the inclusion of all relevant diagnoses in clinical practice.     

Prospective assessment of treatment use by patients with personality disorders

OBJECTIVE: This study examined the utilization of mental health treatments over a three-year period among patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorders compared with patients with major depressive disorder and no personality disorder. METHODS: A prospective, longitudinal study design was used to measure treatment use for 633 individuals aged 18 to 45 years during a three-year period. RESULTS: Patients with borderline personality disorder were significantly more likely than those with major depressive disorder to use most types of treatment. Furthermore, all patients continued using high-intensity, low-duration treatments throughout the study period, whereas individual psychotherapy attendance declined significantly after one year. CONCLUSIONS: Although our data showed that patients with borderline personality disorder used more mental health services than those with major depressive disorder, many questions remain about the adequacy of the treatment received by all patients with personality disorders.     

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.     

Personality disorders evident by early adulthood and risk for anxiety disorders during middle adulthood

Data from the Children in the Community Study, a prospective longitudinal investigation, were used to investigate the association of personality disorder (PD) traits, evident by early adulthood, with risk for development of anxiety disorders by middle adulthood. Individuals without a history of anxiety disorders who met diagnostic criteria for >or=1 PD by early adulthood were at markedly elevated risk for agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder, and panic disorder by middle adulthood. Antisocial, avoidant, borderline, dependent, depressive, histrionic, obsessive-compulsive, passive-aggressive, and schizotypal PD traits, evident by early adulthood, were associated with elevated risk for >or=1 anxiety disorder during middle adulthood. These associations remained significant after a history of anxiety disorder and co-occurring Axis I psychiatric disorder was controlled statistically. Findings of this study suggest that some types of PD traits that become evident by early adulthood may contribute to increased risk for the development of anxiety disorders by middle adulthood.     

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.     

Childhood trauma, borderline personality, and eating disorders: a developmental cascade

In this article, we discuss the nature and role of trauma in relationship to borderline personality disorder and eating disorders. As is clinically evident, trauma can result in a variety of psychological consequences. These consequences include both Axis I and II disorders. Among the Axis II disorders, trauma appears to heighten the risk for the development of borderline, antisocial, avoidant, paranoid, and even schizotypal personality disorders. Likewise, trauma may heighten the risk for developing an eating disorder. There appear to be complex inter-relationships among trauma, borderline personality disorder, and eating disorders. In this article, we attempt to summarize these inter-relationships.     

Dimensional representations of DSM-IV personality disorders: relationships to functional impairment

OBJECTIVE: This study compared three-dimensional representations of DSM-IV personality disorders and standard categories with respect to their associations with psychosocial functioning. METHOD: Six hundred sixty-eight patients with semistructured interview diagnoses of schizotypal, borderline, avoidant, or obsessive-compulsive personality disorders or with major depressive disorder and no personality disorder completed questionnaires assessing three-factor and five-factor dimensional models of personality. Personality disorder categories, dimensional representations of the categories based on criteria counts, and three- and five-factor personality dimensions were compared on their relationships to impairment in seven domains of functioning, as measured by the Longitudinal Interval Follow-up Evaluation-Baseline Version. RESULTS: Both the categorical and dimensional representations of DSM-IV personality disorders had stronger relationships to impairment in functioning in the domains of employment, social relationships with parents and friends, and global social adjustment and to DSM-IV axis V ratings than the three- and five-factor models. DSM-IV dimensions predicted functional impairment best of the four approaches. Although five-factor personality traits captured variance in functional impairment not predicted by DSM-IV personality disorder dimensions, the DSM-IV dimensions accounted for significantly more variance than the measures of personality. CONCLUSIONS: Scores on dimensions of general personality functioning do not appear to be as strongly associated with functional impairment as the psychopathology of DSM personality disorder. A compromise in the ongoing debate over categories versus dimensions of personality disorder might be the dimensional rating of the criteria that comprise traditional categories.     

Personality traits and disorders in obsessive-compulsives

The Personality Diagnostic Questionnaire (PDQ) was completed by significant others for 26 obsessive-compulsive disorder (OCD) patients. Personality traits and diagnoses were scored. Profiles indicated that only one patient met criteria for compulsive personality, whereas one quarter to one third of the sample met criteria for avoidant, histrionic, schizotypal, and dependent personality disorders. High mean percentages on traits scores were found for avoidant and dependent traits, as well as for passive-aggressive and compulsive ones. Patients with more personality traits provoked more negative familial reactions and were less socially adjusted, but they did not have more OCD symptoms at pretest. Personality diagnoses did not predict behavioral treatment outcome. High dependent personality trait scores were related to better post-test gains, whereas passive-aggressive ones were associated with poorer long-term benefits. Results are discussed in light of recent reports of personality disorder in OCD and in other anxiety disorder patients. Methodological concerns are delineated.     

Prospective investigation of a PTSD personality typology among individuals with personality disorders

This study investigated the replicability of a previously proposed personality typology of posttraumatic stress disorder (PTSD, and explored stability of cluster membership over a 6-month period. Participants with current PTSD (n = 156) were drawn from the Collaborative Longitudinal Personality Disorders Study (CLPS). The CLPS project tracked a large sample of individuals who met criteria for 1 of 4 target diagnoses (borderline, schizotypal, avoidant, and obsessive-compulsive) and a contrast group of individuals who met criteria for depression but no personality disorder. A cluster analysis using scales from the Schedule of Nonadaptive and Adaptive Personality yielded 3 clusters: "internalizing," "externalizing," and "low pathology." Using K-means cluster analysis, the results did not replicate previous work. Using Ward's method, the hypothesized 3-cluster structure was confirmed at baseline but did not demonstrate temporal stability at 6 months.     

An open, noncomparative study of amoxapine in borderline disorders

Five patients with borderline personality disorder (BPD) and 5 patients with schizotypal personality disorder (SPD) completed at least 3 weeks of treatment with amoxapine. The patients fulfilled DSM-III criteria for borderline disorders and scored 7 points or more in Gunderson's Diagnostic Interview for Borderlines (DIB). The final median medication in patients with BPD was 200 mg amoxapine/day and 42 mg oxazepam/day. Duration of treatment averaged 28 days. In patients with SPD the corresponding figures were 250 mg amoxapine/day, 36 mg oxazepam/day and 39 days. The study suggests that amoxapine improves schizophrenic-like and depressive symptoms in patients with schizotypal personality disorders (SPD). No effect could be shown in patients with borderline personality disorders (BPD).     

Neuroimaging and personality disorders

Within the past several years, neuroimaging research on personality disorders has begun to develop. Personality disorders can be thought of as trait-like dysfunctional patterns in cognitive, affective, impulse control, and interpersonal domains. These domains of dysfunction have been linked to specific neural circuits. Developments in brain imaging techniques have allowed researchers to examine the neural integrity of these circuits in personality-disordered individuals. This article reviews the neuroimaging literature on borderline personality disorder, antisocial personality disorder (including psychopathy) and schizotypal personality disorder. Functional and structural studies provide support for dysfunction in fronto-limbic circuits in borderline and antisocial personality disorder, whereas temporal lobe and basal striatal-thalamic compromise is evident in schizotypal personality disorder.     

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.     

Personality diagnosis and illness diagnosis

This case presented with features of affective disorder with psychosis and also of borderline, avoidant and schizotypal personality disorders. During the course of subsequent treatment there was a marked reduction not only in psychotic and depressive features, but also in criteria for personality disorder, especially borderline. Relevant literature is reviewed and the importance of treatable illness as a possible cause of apparent personality disorder is discussed.     

Ethnicity and four personality disorders

The current study examined the relationship between ethnicity and DSM-IV personality disorders. The distribution of four personality disorders--borderline (BPD), schizotypal (STPD), avoidant (AVPD), and obsessive-compulsive (OCPD)--along with their criteria sets, were compared across three ethnic groups (Caucasians, African Americans, and Hispanics) using both a clinician-administered diagnostic interview and a self-report instrument. Participants were 554 patients drawn from the Collaborative Longitudinal Personality Disorders Study (CLPS) who comprised these three ethnic groups and met personality disorder criteria based on reliably administered semistructured interviews. Chi-square analyses revealed disproportionately higher rates of BPD in Hispanic than in Caucasian and African American participants and higher rates of STPD among African Americans when compared to Caucasians. Self-report data reflected similar patterns. The findings suggest that in treatment-seeking samples, Caucasians, Hispanics, and African Americans may present with different patterns of personality pathology. The factors contributing to these differences warrant further investigation.