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.     

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.     

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.     

Lifetime and 12-month prevalence of DSM-IV psychiatric disorders among Korean adults

The objective was to estimate the prevalence and correlates of psychiatric disorders in a nationwide sample of Korean adults. Face-to-face interviews were conducted with the Korean version of Composite International Diagnostic Interview 2.1/DSM-IV (N = 6275, response rate 79.8%). The lifetime and 12-month prevalences for all types of DSM-IV disorders were 33.5% and 20.6%, respectively. Those of specific disorders were as follows: 17.2% and 7.1% for alcohol use disorder, 11.2% and 7.4% for nicotine use disorder, 5.2% and 4.2% for specific phobia, 4.3% and 1.7% for major depressive disorder, and 2.3% and 1.0% for generalized anxiety disorder. Among the sociodemographic variables, widowed status, higher income, and rural residence were the risk factors for both lifetime major depressive disorder and alcohol use disorder after controlling for gender, age, and education. The prevalence of psychiatric disorders was higher than those observed in other East-Asian countries and most European countries, but lower than that in the United States. Alcohol use disorder was particularly high in Korea.     

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.     

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.     

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.     

Race-ethnicity and the prevalence and co-occurrence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, alcohol and drug use disorders and Axis I and II disorders: United States, 2001 to 2002

The objective of this study was to compare the current prevalence and co-occurrence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, alcohol and drug use disorders and mood, anxiety, and personality disorders among whites, blacks, Native Americans, Asians, and Hispanics in a large representative sample of the US population. Striking mental health disparities were observed in the prevalences of psychiatric disorders, especially among Native Americans. Disparities in psychiatric comorbidity differed from those associated with prevalence. Most significantly, the association between alcohol disorders and personality disorders was significantly greater among Asians relative to whites, blacks, and Native Americans, despite lower prevalences of these disorders among Asians. Taken together, the results of this study highlight the need of future studies that help unravel the risk factors underlying the disparities in both prevalence and comorbidity of psychiatric disorders observed among race-ethnic groups in the United States.     

Obsessive-compulsive disorder among African Americans and blacks of Caribbean descent: results from the National Survey of American Life

Background: There is limited research regarding the nature and prevalence of obsessive‐compulsive disorder (OCD) among various racial and ethnic subpopulations within the United States, including African Americans and blacks of Caribbean descent. Although heterogeneity within the black population in the United States has largely been ignored, notable differences exist between blacks of Caribbean descent and African Americans with respect to ethnicity, national heritage, and living circumstances. This is the first comprehensive examination of OCD among African Americans and blacks of Caribbean descent. Methods: Data from the National Survey of American Life, a national household probability sample of African Americans and Caribbean blacks in the United States, were used to examine rates of OCD among these groups. Results: Lifetime and 12‐month OCD prevalence estimates were very similar for African Americans and Caribbean blacks. Persistence of OCD and rates of co‐occurring psychiatric disorders were very high and also similar between African American and Caribbean black respondents. Both groups had high levels of overall mental illness severity and functional impairment. Use of services was low for both groups, particularly in specialty mental health settings. Use of anti‐obsessional medications was also rare, especially among the Caribbean black OCD population. Conclusions: OCD among African Americans and Caribbean blacks is very persistent, often accompanied by other psychiatric disorders, and is associated with high overall mental illness severity and functional impairment. It is also likely that very few blacks in the United States with OCD are receiving evidence‐based treatment and thus considerable effort is needed to bring treatment to these groups. Depression and Anxiety, 2008. Published 2008 Wiley‐Liss, Inc.     

Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey replication

CONTEXT: There is growing recognition that bipolar disorder (BPD) has a spectrum of expression that is substantially more common than the 1% BP-I prevalence traditionally found in population surveys. OBJECTIVE: To estimate the prevalence, correlates, and treatment patterns of bipolar spectrum disorder in the US population. DESIGN: Direct interviews. SETTING: Households in the continental United States. PARTICIPANTS: A nationally representative sample of 9282 English-speaking adults (aged >or=18 years). MAIN OUTCOME MEASURES: Version 3.0 of the World Health Organization's Composite International Diagnostic Interview, a fully structured lay-administered diagnostic interview, was used to assess DSM-IV lifetime and 12-month Axis I disorders. Subthreshold BPD was defined as recurrent hypomania without a major depressive episode or with fewer symptoms than required for threshold hypomania. Indicators of clinical severity included age at onset, chronicity, symptom severity, role impairment, comorbidity, and treatment. RESULTS: Lifetime (and 12-month) prevalence estimates are 1.0% (0.6%) for BP-I, 1.1% (0.8%) for BP-II, and 2.4% (1.4%) for subthreshold BPD. Most respondents with threshold and subthreshold BPD had lifetime comorbidity with other Axis I disorders, particularly anxiety disorders. Clinical severity and role impairment are greater for threshold than for subthreshold BPD and for BP-II than for BP-I episodes of major depression, but subthreshold cases still have moderate to severe clinical severity and role impairment. Although most people with BPD receive lifetime professional treatment for emotional problems, use of antimanic medication is uncommon, especially in general medical settings. CONCLUSIONS: This study presents the first prevalence estimates of the BPD spectrum in a probability sample of the United States. Subthreshold BPD is common, clinically significant, and underdetected in treatment settings. Inappropriate treatment of BPD is a serious problem in the US population. Explicit criteria are needed to define subthreshold BPD for future clinical and research purposes.     

Emotional support,negative interaction and major depressive disorder among African Americans and Caribbean Blacks: findings from the National Survey of American Life

Objectives  

Few studies have examined the association between social support, negative interaction, and major depressive disorder among representative samples of racial and ethnic minority groups. This study investigates the relationship between emotional support and negative interaction with family members on lifetime major depressive disorder among African Americans and Caribbean Blacks.     

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.     

Perceived colorism and lifetime psychiatric disorders among Black American adults: findings from the National Survey of American Life

Colorism has been propagated across the globe, and skin tone discrimination may partly explain social stratification and health disparities within the Black American population. Using data from a large probability sample of Black American adults (National Survey of American Life; 2001–2003), we examined the relations between perceived colorism and psychiatric disorders. In multivariable logistic regression models, in-group colorism was associated with greater odds of having any lifetime psychiatric disorder (aOR: 1.20; 95% CI: 1.08–1.32; p = 0.00); however, out-group colorism was not significantly associated, net of sociodemographic characteristics and in-group colorism (aOR: 1.08; 95% CI: 0.99–1.18; p = 0.08). When looking at specific disorders, in-group colorism was significantly associated with greater odds of alcohol use disorder, substance use disorder, anxiety disorder, and eating disorder, but was not associated with post-traumatic stress disorder or mood disorder. Out-group colorism was not significantly associated with any psychiatric disorder except anxiety disorder. Our findings show that colorism predicts psychiatric disorders, though more research is needed to understand why the effects of in-group and out-group colorism are related to certain psychiatric disorders but not others.

     

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.