Latent structure of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition personality disorder criteria

Aims

This study investigated the internal construct validity of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) personality disorders and explored alternative models to characterize the personality disorder traits. The relationship between the obtained personality disorder dimensions and measures of functioning and disability was examined.

Methods

The subjects in the study were 742 community-residing individuals who participated in the Hopkins Epidemiology of Personality Disorders Study. The presence of DSM-IV personality disorder traits was assessed by psychologists using the International Personality Disorder Examination (IPDE). Confirmatory factor analysis was performed on all the IPDE criteria for each of the 10 personality disorders using the Mplus program. Exploratory factor analysis of all personality disorder traits was completed using the same program. Factor scores were correlated with subjects' GAF ratings and number of missed days from work for physical and psychological reasons.

Results

A single underlying factor was found for the IPDE item criteria of avoidant and dependent personality disorder, with less evidence for the other 8 personality disorders. Five factors were retained as the dimensional accounting for the personality disorder criteria. These factors were named compulsive, neurotic avoidant, aloof, impulsive callous, and egocentric. Of the five factors, 4 were associated with evidence of diminished functioning.

Conclusions

The IPDE pathological personality traits did not empirically cluster according to the current DSM-IV axis II diagnostic system but instead defined 5 relatively independent PD symptom dimensions that were related to functional impairments.     

The quality of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition dependent personality disorder prototype

OBJECTIVE: The aim of this study was to investigate the quality of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition dependent personality disorder (DPD) prototype with special reference to possible bidimensionality. METHOD: The sample included 1078 patients, 81% (n = 875) had 1 or more personality disorders. The proportion of patients with DPD was 11.3% (n = 122). Frequency distribution, chi2, correlations, reliability statistics, exploratory and confirmatory factor analyses were performed. RESULTS: Of the DPD criteria, criterion 3 showed a higher correlation with avoidant personality disorder than with DPD itself, whereas criterion 5 was weakly correlated with DPD, findings being confirmed by an exploratory factor analysis and a low internal consistency of all DPD criteria. An a priori hypothesized 2-factor model was confirmed by the confirmatory factor analysis. CONCLUSIONS: These results indicate a moderate to low quality of the DPD construct. The main objection is that DPD is based too heavily on a bidimensional model of perceived incompetence and dysfunctional attachment. Items should be revised, in particular, items 3 and 5.     

Validity aspects of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, narcissistic personality disorder construct

Background

The Diagnostic and Statistical Manual of Mental Disorders (DSM), Fourth Edition, narcissistic personality disorder (NPD) construct has been criticized for being too narrowly defined, for example, by focusing on overt grandiosity at the expense of exhibitionism and narcissistic vulnerability and thus covering only parts of the domain of narcissism. The purpose of this study was to elucidate several validity aspects of the NPD construct.

Methods

The material consisted of data from 2277 patients (80% of whom had a personality disorder [PD]) who were admitted to units connected to The Norwegian Network of Psychotherapeutic Day Hospitals. The Axis II diagnoses were assessed by Structured Clinical Interview for DSM, Fourth Edition, Axis II Personality Disorders.

Results

The frequency of NPD was very low (0.8%). Male patients were overrepresented both on a diagnostic level and on criteria levels. The NPD category was positively associated with other cluster B disorders and negatively associated with avoidant PD. The criteria “demands excessive admiration” and “fantasies of unlimited success” correlated almost as highly with the histrionic PD category and loaded primarily on a histrionic factor. The dominant NPD factor also included the antisocial criterion of “showing no regret having injured others.” The major part of the patients' personality pathology could be attributed to other PD criteria.

Conclusions

The results challenge the notion of NPD as a distinct diagnostic category. Rather, narcissism should be conceived as personality dimensions pertinent to the whole range of PDs. The results support the views put forward by Russ et al (Refining the construct of narcissistic personality disorder: diagnostic criteria and subtypes. Am J Psychiatry 2008;11:1473-1481) that what clinicians conceive as narcissism consists of several subtypes (dimensions). Our data support the existence of a grandiose/malignant type and an exhibitionistic type. Unfortunately, there was no measure of hypersensitivity. The proposal to delete NPD as a prototype category in the DSM, Fifth Edition, seems well justified. However, the proposed trait domain of antagonism in the DSM, Fifth Edition, seems to account better for the grandiose/malignant dimension than the exhibitionistic/histrionic dimension.     

An investigation of the validity of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition avoidant personality disorder construct as a prototype category and the psychometric properties of the diagnostic criteria

This study investigated several aspects of the validity of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition avoidant personality disorder (APD) construct, with emphasis on the psychometric properties of the diagnostic criteria and the prototype nature of the construct. A sample of 1,058 patients from the Norwegian Network of Psychotherapeutic Day Hospitals was examined by means of exploratory factor analysis, correlation, and diagnostic efficiency statistics, chi(2) analysis, and frequency distribution. The results indicated that APD is a 1-dimensional construct with good internal consistency. The criteria had acceptable diagnostic efficiency; criterion 3 performed poorest. Number of APD criteria showed no distinct threshold between No-APD and patients with APD. Sixty-two different combinations of any 4 APD criteria occurred. It can be concluded that the prototype model fitted the data well and that the APD diagnostic criteria perform well in the current classification system. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition hierarchy of criteria was not supported.     

A latent structure analysis of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Narcissistic Personality Disorder criteria

The aim of this study was to examine the latent structure of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), Narcissistic Personality Disorder (NPD) criteria in a group of 641 outpatients. The consecutively admitted outpatients were administered the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, Version 2.0, and the Personality Questionnaire. Both confirmatory and exploratory factor analyses (CFA and EFA, respectively) were used to evaluate whether the NPD criteria measure a single latent trait. Latent class analysis was used to assess the diagnostic accuracy of the individual DSM-IV NPD criteria. Mean above minus below a cut (MAMBAC) and maximum covariance (MAXCOV) taxometric analyses were used to evaluate whether the latent distribution of the DSM-IV NPD features is actually discrete. Both CFA and EFA results showed that the 9 DSM-IV NPD criteria loaded on 2 correlated factors. The latent class analysis results suggested a 3-class solution for NPD criteria; relevant differences in diagnostic efficiency were observed among the NPD criteria. MAMBAC and MAXCOV analyses provided consistent evidence of taxonic (ie, discrete) latent structure for NPD. This study gave only partial support to the validity of the DSM-IV NPD construct. Taxometric analyses indicated that a typological model is appropriate for describing NPD, but CFA and EFA suggested the existence of 2 distinct-albeit correlated-clusters of narcissistic features. As a whole, the DSM-IV criteria discriminated NPD from other personality disorders, but diagnostic accuracy statistics did not replicate the rank order of diagnostic efficiency of NPD criteria proposed by the DSM-IV.     

Intermittent explosive disorder: development of integrated research criteria for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

This study was designed to develop a revised diagnostic criteria set for intermittent explosive disorder (IED) for consideration for inclusion in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). This revised criteria set was developed by integrating previous research criteria with elements from the current DSM-IV set of diagnostic criteria. Evidence supporting the reliability and validity of IED-IR (“IED Integrated Criteria”) in a new and well-characterized group of subjects with personality disorder is presented. Clinical, phenomenologic, and diagnostic data from 201 individuals with personality disorder were reviewed. All IED diagnoses were assigned using a best-estimate process (eg, kappa for IED-IR >0.85). In addition, subjects meeting IED-IR criteria had higher scores on dimensional measures of aggression and had lower global functioning scores than non–IED-IR subjects, even when related variables were controlled. The IED-IR criteria were more sensitive than the DSM-IV criteria only in identifying subjects with significant impulsive-aggressive behavior by a factor of 16. We conclude that the IED-IR criteria can be reliably applied and have sufficient validity to warrant consideration as DSM-V criteria for IED.     

The relationship between the five-factor model and latent Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition personality disorder dimensions

This study compared the latent structure of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition personality disorders (PDs) with the 5-factor model (FFM) of general personality dimensions. The subjects in the study were 742 community-residing individuals who participated in the Hopkins Epidemiology of Personality Disorders Study. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition PD traits were assessed by psychologists using the International Personality Disorder Examination, and PD dimensions were derived previously using dichotomous factor analysis. The Revised NEO Personality Inventory, a measure of the FFM, was administered to all subjects. The relationship between the 2 sets of personality-related constructs was examined using a construct validity framework and also using Pearson correlation coefficients, multiple linear regression models, and spline regression models. The 5 PD factors each exhibited small to moderate correlations with several NEO dimensions; together, the NEO domain and facet scores explained a fifth to a third of the variance in PD dimensions. Examples of nonlinear relationships between the personality dimensions were identified. There is a modest correspondence between the PD dimensions and FFM traits, and the traits of FFM only partially explain the variance of the PDs. Dimensional measures of general personality may be a suitable alternative to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Whether additional maladaptive traits would better define the domain of PDs remains an important objective for future research.     

抑郁障碍共患其他精神障碍的研究

目的　探讨抑郁障碍与其他精神障碍的共患率及其对抑郁障碍患者的影响。方法经美国精神障碍诊断与统计手册第4版轴Ⅰ障碍用定式临床检查-临床版评定,对符合抑郁障碍诊断的366例患者评定汉密尔顿抑郁量表(HAMD)、汉密尔顿焦虑量表(HAMA)和临床疗效总评量表病情严重程度(CGI SI)。结果　(1)38 2%的抑郁症患者当前至少共患焦虑障碍、心境恶劣障碍、物质使用障碍、躯体形式障碍和饮食障碍等5种障碍中的1种。其中焦虑障碍共患率最高(26 5%, 97例),其次为心境恶劣障碍(13 4%, 49例),均高于共患其他3种障碍(P<0 01);而其他3种障碍共患率之间的差异无统计学意义。( 2 )共患焦虑障碍和心境恶劣障碍者的HAMD分别为( 29 25±6 22)分和(30 15±6 15 )分,HAMA分别为( 22 01±5 61 )分和( 20 36±5 36 )分,CGI SI分别为(5 32±0 99)分和(4 76±1 12)分,均高于无共患者[分别为( 26 02±6 06 )分, ( 16 76±5 26 )分,(4 02±1 08)分;均P<0 01]。( 3 )共患焦虑障碍和心境恶劣障碍的抑郁症患者中分别有84%和82%的患者期望治疗共患障碍。结论　抑郁障碍常共患焦虑障碍和心境恶劣障碍;其焦虑抑郁症状更严重,更期望治疗所共患的障碍。     

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Defensive Functioning Scale: a validity study

Objective

We assess the convergent and predictive validity of the Defensive Functioning Scale (DFS) with measures of life events, including childhood abuse and adult partner victimization; dimensions of psychopathology, including axis I (depressive) and axis II (borderline personality disorder) symptoms; and quality of object relations.

Method

One hundred and ten women from a university-based urban primary care clinic completed a research interview from which defense mechanisms were assessed. The quality of object relations was also assessed from interview data. The women completed self-report measures assessing depression, borderline personality disorder symptoms, childhood physical and sexual abuse, and adult partner physical and sexual victimization.

Results

Inter-rater reliability of the scoring of the DFS levels was good. High adaptive defenses were positively correlated with the quality of object relations and pathological defenses were positively correlated with childhood and adult victimization and symptom measures. Although major image distorting defenses were infrequently used, they were robustly correlated with all study variables. In a stepwise multiple regression analysis, major image distorting defenses, depressive symptoms, and minor image distorting defenses significantly predict childhood victimization, accounting for 37% of the variance. In a second stepwise multiple regression analysis, borderline personality disorder symptoms and disavowal defenses combined to significantly predict adult victimization, accounting for 16% of the variance.

Conclusions

The DFS demonstrates good convergent validity with axis I and axis II symptoms, as well as with measures of childhood and adult victimization and object relations. The DFS levels add nonredundant information to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition beyond axis I and axis II.     

A Persian translation of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: psychometric properties

Objective

The aim of this study is to assess the reliability and validity of a Persian translation of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I Disorders (SCID-I) through a multicenter study in a clinical population in Iran.

Method

The sample consisted of 299 subjects admitted to outpatient or inpatient services of 3 psychiatric centers in Tehran, Iran. The SCID was administered by trained interviewers. To study the test-retest reliability, a second independent SCID interview was administered to 104 of the entire sample within 3 to 7 days of the first interviews. For the assessment of validity, the SCID diagnoses were compared with the consensus clinical diagnoses made by 2 psychiatrists for all 299 patients.

Results

Diagnostic agreements between test and retest SCID administration were fair to good for most diagnostic categories. Overall weighted κ was 0.52 for current diagnoses and 0.55 for lifetime diagnoses. Specificity values for most psychiatric disorders were high (>0.85); the sensitivity values were somewhat lower.

Conclusions

The Persian translation of the SCID yields diagnoses with acceptable to good reliability and validity in a clinical population in Iran. This supports the cross-cultural use of the instrument.     

Dimensional models of personality disorder: Diagnostic and Statistical Manual of Mental Disorders Fifth Edition and beyond

PURPOSE OF REVIEW: We describe several dimensional models of personality disorders and highlight future directions for the integration of dimensional approaches in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). This review is timely and relevant, given the upcoming revision of DSM (DSM-V). RECENT FINDINGS: Research has identified four common higher order factors that could be used to characterize personality pathology. Evidence supports the inclusion of this dimensional representation of personality disorders in DSM-V, possibly as an adjunct to the traditional categorical classification scheme. A dimensional approach would ameliorate many of the problems associated with the categorical approach. Issues that still need to be addressed are on how to integrate these dimensions into the current classification system in a way that they will be accepted by clinicians and psychopathologists. The clinical utility of the dimensional models must be demonstrated, and the development of a method that combines trait elevations and impairment associated with personality pathology is needed in order to define personality disorder from a dimensional perspective. SUMMARY: Although there may be some initial resistance to the incorporation of the dimensional models in the future diagnostic manuals, researchers and clinicians are expected to benefit from the more reliable and valid portrayal of personality pathology.     

Telephone versus face-to-face administration of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, for diagnosis of psychotic disorders

ObjectiveThe current study aims to compare telephone vs face-to-face administration of the version of Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (SCID) for diagnosis of “any psychotic disorder” in a clinical population in Iran.MethodThe sample consisted of 72 subjects from 2 psychiatric outpatient services in Tehran, Iran. The subjects were interviewed using face-to-face SCID for the purpose of diagnosing psychotic disorders. A second independent telephone SCID was administered to the entire sample within 5 to 10 days, and the lifetime and 12-month diagnoses were compared.ResultsThe positive likelihood ratio of telephone-administered SCID for diagnosis of “any lifetime psychotic disorder” was 5.1 when compared with the face-to-face SCID. The value for the primary psychotic disorders in the past 12 months was lower (2.3).ConclusionsThe data indicate that telephone administration of the SCID is an acceptable method to differentiate between subjects with lifetime psychotic disorders and those who have had no psychotic disorders and provides a less resource-demanding alternative to face-to-face assessments.     

Irritable mood and the Diagnostic and Statistical Manual of Mental Disorders

Background  

The terms 'irritable mood' and 'irritability' have been applied to describe and define a variety of different categories in the Diagnostic and Statistical Manual of Mental Disorders (DSM). More precise diagnostic terms and concepts are needed.     

Factor structure and diagnostic efficiency of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for avoidant personality disorder in Hispanic men and women with substance use disorders

Objective

This study examined the internal consistency, factor structure, and diagnostic efficiency of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), criteria for avoidant personality disorder (AVPD) and the extent to which these metrics may be affected by sex.

Method

Subjects were 130 monolingual Hispanic adults (90 men, 40 women) who had been admitted to a specialty clinic that provides psychiatric and substance abuse services to Spanish-speaking patients. All were reliably assessed with the Spanish-Language Version of the Diagnostic Interview for DSM-IV Personality Disorders. The AVPD diagnosis was determined by the best-estimate method. After evaluating internal consistency of the AVPD criterion set, an exploratory factor analysis was performed using principal components extraction. Afterward, diagnostic efficiency indices were calculated for all AVPD criteria. Subsequent analyses examined men and women separately.

Results

For the overall group, internal consistency of AVPD criteria was good. Exploratory factor analysis revealed a 1-factor solution (accounting for 70% of the variance), supporting the unidimensionality of the AVPD criterion set. The best inclusion criterion was “reluctance to take risks,” whereas “interpersonally inhibited” was the best exclusion criterion and the best predictor overall. When men and women were examined separately, similar results were obtained for both internal consistency and factor structure, with slight variations noted between sexes in the patterning of diagnostic efficiency indices.

Conclusions

These psychometric findings, which were similar for men and women, support the construct validity of the DSM-IV criteria for AVPD and may also have implications for the treatment of this particular clinical population.