Convergence of the dimensional assessment of personality pathology (DAPP-BQ) and the five-factor personality inventory for the international classification of diseases 11th edition (FFiCD) in the context of the five-factor model and personality disorders.

The current manuscript presents the convergence of the Dimensional Assessment of Personality Pathology (DAPP-BQ), using its short form the DAPP-90, and the Five-Factor Personality Inventory for International Classification of Diseases (ICD-11), the FFiCD, in the context of the five-factor personality model and the categorical approach of personality disorders (PDs). The current manuscript compares the predictive validity of both the FFiCD and the DAPP-90 regarding personality disorder scales and clusters. Results demonstrate a very high and meaningful convergence between the DAPP-90 and the FFiCD personality pathology models and a strong alignment with the FFM. The DAPP-90 and the FFiCD also present an almost identical predictive power of PDs. The DAPP-90 accounts for between 18% and 47%, and the FFiCD between 21% and 47% of PDs adjusted variance. It is concluded that both DAPP-90 and FFiCD questionnaires measure strongly similar pathological personality traits that could be described within the frame of the FFM. Additionally, both questionnaires predict a very similar percentage of the variance of personality disorders.

Measurement invariance of the inventory of Callous­Unemotional traits in different age groups from preschool age to late adolescence in Germany.

BACKGROUND: Callous-unemotional traits are associated with the development of severe behavior problems, delinquency, and psychopathy. Previous studies have repeatedly shown that CU traits may be present as early as preschool age, and they have consistently used the Inventory of Callous-Unemotional Traits (ICU) to assess CU traits in children and adolescents. A three-factor structure for the ICU has been widely endorsed. METHOD: The aim of our study is to compare the three-factor structure of the ICU in different age groups (preschool, middle childhood, early, and late adolescence) and to test for measurement invariance in a German sample of N = 2368 children and adolescents (M = 11.76 years; SD = 3.72). RESULTS: The results of our study indicate configural measurement invariance, suggesting that the ICU has the same structure in all age groups but with different meanings, parameters, and mean values in the groups. CONCLUSION: Accordingly, the ICU cannot be applied in the same way to children and adolescents of different age groups, which emphasizes the need for a more differentiated assessment.

Test-retest reliability of the HEXACO-100-And the value of multiple measurements for assessing reliability.

Despite the widespread use of the HEXACO model as a descriptive taxonomy of personality traits, there remains limited information on the test-retest reliability of its commonly-used inventories. Studies typically report internal consistency estimates, such as alpha or omega, but there are good reasons to believe that these do not accurately assess reliability. We report 13-day test-retest correlations of the 100- and 60-item English HEXACO Personality Inventory-Revised (HEXACO-100 and HEXACO-60) domains, facets, and items. In order to test the validity of test-retest reliability, we then compare these estimates to correlations between self- and informant-reports (i.e., cross-rater agreement), a widely-used validity criterion. Median estimates of test-retest reliability were .88, .81, and .65 (N = 416) for domains, facets, and items, respectively. Facets' and items' test-retest reliabilities were highly correlated with their cross-rater agreement estimates, whereas internal consistencies were not. Overall, the HEXACO Personality Inventory-Revised demonstrates test-retest reliability similar to other contemporary measures. We recommend that short-term retest reliability should be routinely calculated to assess reliability.

Effects of subclinical emotional and behavioral problems on metabolic control in adolescents with type 1 diabetes: Role of maternal and adolescent personality traits.

BACKGROUND: Personality traits of adolescents with type 1 diabetes mellitus (T1DM) and those of their mothers may lead to poor glycemic control through psychiatric comorbidity. However, it is not yet known how the personality traits of adolescents with T1DM and those of their mothers affect metabolic control in the absence of or before the development of psychiatric disorders. We aimed to determine the effects of subclinical emotional and behavioral problems, as well as maternal and own personality traits, on metabolic control in adolescents with T1DM. METHODS: A total of 48 adolescents with diabetes (19 females and 29 males), with a median age of 14 years, who did not meet diagnostic criteria for a psychiatric condition, and their mothers completed the Junior Temperament and Character Inventory (J-TCI) as well as the adolescent and parent forms of the Strengths and Difficulties Questionnaire (SDQ) and the TCI for adults. The mean HbA1c levels measured in the past year were obtained from medical records. RESULTS: Personality traits and the emotional and behavioral difficulties in adolescents with poor metabolic control were similar to those with good metabolic control (p>.05). However, the self-directedness and cooperativeness subscale scores of the TCI completed by the mothers of those in the poor metabolic control group were significantly lower than the others: 25.5 vs. 30.4; t(39)= 3.737, p= .001, and 27.3 vs. 31.5; t(46)= 2.759, p= .008; respectively. CONCLUSION: Our study showed that adolescents' personality and subclinical symptoms were not related to HbA1c levels in the absence of psychiatric comorbidity, while some maternal personality traits were associated with metabolic control. Management of T1DM should be tailored to adolescents and their needs with the proper involvement of mothers.

Narcissistic personality traits and prefrontal brain structure.

Narcissistic traits have been linked to structural and functional brain networks, including the insular cortex, however, with inconsistent findings. In this study, we tested the hypothesis that subclinical narcissism is associated with variations in regional brain volumes in insular and prefrontal areas. We studied 103 clinically healthy subjects, who were assessed for narcissistic traits using the Narcissistic Personality Inventory (NPI, 40-item version) and received high-resolution structural magnetic resonance imaging. Voxel-based morphometry was used to analyse MRI scans and multiple regression models were used for statistical analysis, with threshold-free cluster enhancement (TFCE). We found significant (p < 0.05, family-wise error FWE corrected) positive correlations of NPI scores with grey matter in multiple prefrontal cortical areas (including the medial and ventromedial, anterior/rostral dorsolateral prefrontal and orbitofrontal cortices, subgenual and mid-anterior cingulate cortices, insula, and bilateral caudate nuclei). We did not observe reliable links to particular facets of NPI-narcissism. Our findings provide novel evidence for an association of narcissistic traits with variations in prefrontal and insular brain structure, which also overlap with previous functional studies of narcissism-related phenotypes including self-enhancement and social dominance. However, further studies are needed to clarify differential associations to entitlement vs. vulnerable facets of narcissism.

Anxious temperament and cyberchondria as mediated by fear of COVID-19 infection: A cross-sectional study.

This study's main goal was to evaluate the association between anxious temperament and the fear of COVID-19-related self-infection and infection in loved ones (family members, friends, relatives) and cyberchondria. The sample consisted of 499 men and women aged between 18 and 72 who were gathered from the general population via an online recruitment platform. A numerical rating scale comprising 11 degrees of fear was used to assess participants' COVID-19-related fear, and affective temperaments were evaluated using Akiskal's Temperament Evaluation of the Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A) scales. Cyberchondria was assessed using McElroy and Shevlin's Cyberchondria Severity Scale (CSS). Small to medium positive correlations were found between depressive, cyclothymic, irritable and anxious temperaments and cyberchondria and between depressive and anxious temperaments and COVID-19 fears. However, no correlation was observed between the hyperthymic temperament and cyberchondria. Cyberchondria positively correlated with both COVID-19 fears scales, though the correlation coefficients were medium. Based on the results of linear regression analysis, only anxious temperament and COVID-19 fear of self-infection were significant predictors of cyberchondria. The analysis also revealed a significant indirect effect of anxious temperament on cyberchondria through fear of COVID-19 self-infection as a mediator between anxious temperament and cyberchondria.

The self- and informant-personality inventories for ICD-11: Agreement, structure, and relations with health, social, and satisfaction variables in older adults.

The International Classification of Diseases-11th Edition (ICD-11) includes a dimensional trait model of personality disorder. The Personality Inventory for ICD-11 (PiCD) was the first self-report measure developed for its assessment. The present study examines the validity of an informant-report version of the PiCD, the Informant-Personality Inventory for ICD-11 (the IPiC), and is the first study to test self-other agreement, ratings from close others, and the criterion validity of both the IPiC and the PiCD for several popular and well-validated measures of life functioning: Life and romantic relationship satisfaction, social support, physical and mental health, depressive symptoms, insomnia symptoms, and cognitive decline. The present study is also the first to examine the IPiC and PiCD in a sample of older adults in the community. Results suggest that the IPiC and the PiCD show moderate self-other agreement, are associated significantly with several important life functioning areas, and have structural validity even at the item level. Further replication and validation are necessary for these instruments, but the IPiC and the PiCD have shown strong validation evidence to date, now including evidence of consensual and criterion validity, in addition to structural validity. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The Effect of Personality Traits on Cognitive Behavioral Therapy Outcomes in Student Pharmacists with Rat Phobia: A Randomized Clinical Trial.

Background: Little is known about which personality traits determine the effectiveness of various types of cognitive-behavioral therapy (CBT) on animal phobia. The objective of the present study was to investigate a possible association between personality traits and the outcome of single- and multi-session CBT. Methods: The present randomized clinical trial was conducted from November 2018 to May 2019 in Shiraz, Iran. Forty female students with rat phobia, who met the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria, were systematically allocated into a single- and a multi-session therapy group (odd numbers one-session treatment, even numbers multi-session treatment). In both groups, the students were gradually exposed to rats as part of the treatment. Psychological measures (state-anxiety, rat phobia, and disgust questionnaires) were used to compare pre- and post-intervention outcomes. Multivariate analysis of covariance was used to assess which personality traits influenced the intervention outcome. The statistical analysis was performed using SPSS (version 20.0) and P values<0.05 were considered statistically significant. Results: Rat phobia was positively and significantly affected by conscientiousness (P=0.001) and agreeableness (P=0.003). Of these personality traits, only a higher degree of conscientiousness resulted in a further reduction of state anxiety after the intervention (P=0.005). There were no significant differences between the pre- and post-intervention outcomes. Conclusion: The outcome of single- and multi-session rat phobia therapies was associated with specific personality traits of the participants, namely conscientiousness and agreeableness. Both intervention methods had an equal effect on reducing rat phobia.

A trait emotional intelligence perspective on schema modes.

Schema modes (or modes) are a key concept in the theory underlying schema therapy. Modes have rarely been related to established models of personality traits. The present study thus investigates the associations between trait emotional intelligence (TEI) and 14 modes, and tests a global TEI-mode factors-general psychological distress mediation model. The study draws on self-report data from 173 inpatients from a German clinic for psychosomatic medicine. Global TEI correlated positively with both healthy modes (happy child and healthy adult) and negatively with 10 maladaptive modes. When modes were regressed on the four TEI factors, six (emotionality), five (well-being), four (sociability), and four (self-control) significant partial effects on 10 modes emerged. In the parallel mediation model, the mode factors internalization and compulsivity fully mediated the global TEI-general psychological distress link. Implications of the results for the integration of modes with traits in general and with TEI in particular as well as implications of low TEI as a transdiagnostic feature of personality malfunctioning are discussed.

Examining the factor structure of the Big Five Inventory-2 personality domains with an adolescent sample.

We examined the within-domain structure of the five domains of personality measured by the Big Five Inventory-2 with data collected from an adolescent sample (N = 838). Three possible factor models were tested: a single factor, correlated facets, and a single factor with correlated residuals. We examined each model controlling for acquiescence, a response bias in which respondents tend to agree/disagree regardless of item content, using two approaches: acquiescence factor and within-person centering of item-level responses. Across each domain, results indicated both the correlated facets and correlated residuals models demonstrated acceptable fit. Accounting for acquiescent responding was generally associated with improved model fit. However, consistent with past struggles in measuring open-mindedness in adolescents, the correlated residuals model with acquiescence as a factor for open-mindedness failed to converge. Regularized structural equation modeling was conducted on this model for open-mindedness and suggested certain residual covariances that contributed to estimation difficulties should be constrained to zero. Advantages of models are discussed with implications for studying the Big Five personality domains in adolescents. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Fluctuations in grandiose and vulnerable narcissistic states: A momentary perspective.

Theories of narcissism emphasize the dynamic processes within and between grandiosity and vulnerability. Research seeking to address this has either not studied grandiosity and vulnerability together or has used dispositional measures to assess what are considered to be momentary states. Emerging models of narcissism suggest grandiosity and vulnerability can further be differentiated into a three-factor structure-Exhibitionistic Grandiosity, Entitlement, and Vulnerability. Research in other areas of maladaptive personality (e.g., borderline personality disorder) has made headway in engaging data collection and analytic methods that are specifically meant to examine such questions. The present study took an exploratory approach to studying fluctuations within and between grandiose and vulnerable states. Fluctuations-operationalized as gross variability, instability, and lagged effects-were examined across three samples (two undergraduate and a community sample oversampled for narcissistic features; total person N = 862, total observation N = 36,631). Results suggest variability in narcissistic states from moment to moment is moderately associated with dispositional assessments of narcissism. Specifically, individuals who are dispositionally grandiose express both grandiosity and vulnerability, and vary in their overall levels of grandiosity and vulnerability over time. On the other hand, dispositionally vulnerable individuals tend to have high levels of vulnerability and low levels of grandiosity. Entitlement plays a key role in the processes that underlie narcissism and narcissistic processes appear unique to the construct and not reflective of broader psychological processes (e.g., self-esteem). Future research should consider using similar methods and statistical techniques on different timescales to study dynamics within narcissism. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Identifying mood disorders and health-related quality of life of individuals submitted to mandatory military service.

OBJECTIVE: To assess the prevalence of mood disorders in Brazilian soldiers. METHODS: A total of 353 soldiers answered the following questionnaires: the Beck Depression Inventory (BDI), the State-Trait Anxiety Inventory (STAI), the Profile of Mood States (POMS), the medical outcomes study SF-36 questionnaire, the Baecke questionnaire to assess the level of habitual physical activity (HPA) and the socioeconomic (SE) status questionnaire. Participants were classified according to their desire to pursue a military career. RESULTS: Accordingly, 246 participants were allocated to a volunteer group (VG) and 107 to a non-volunteer group (NVG). According to the BDI data for both groups, 66.5% of the soldiers showed at least mild depressive symptoms. Additionally, the STAI data revealed that 27.8% and 8.4% of the soldiers showed high scores on state anxiety and trait anxiety, respectively. The POMS scores were higher in the NVG compared to the VG (Δ%=+263%, p<0.0001). Of the eight subscales, the SF-36 questionnaire showed statistical differences between the groups in the following five dimensions: functioning capacity (p = 0.0046), pain (p = 0.0011), vitality (p < 0.0001), role limitations due to emotional problems (p < 0.0001) and mental health (p < 0.0001). CONCLUSIONS: Mood disorder levels were higher and health status and related quality of life levels were lower in the NVG as compared to the VG.

A longitudinal study of personality traits, anxiety, and depressive disorders in young adults.

BACKGROUND: How personality traits, anxiety, and depressive disorders relate longitudinally has implications for etiologic research and prevention. We sought to determine how neuroticism and extraversion relate to first-onset anxiety and depressive disorders in young adults. DESIGN: An inception cohort of 489 university freshmen was followed for 6 years. METHOD: Participants self-reported personality traits using the Eysenck Personality Questionnaire. Anxiety and depressive disorders were assessed using the Diagnostic Interview Schedule. RESULTS: Baseline neuroticism predicted first-onset panic disorder, agoraphobia, generalized anxiety disorder (GAD), and major depressive disorder (MDD), while introversion predicted first-onset agoraphobia (moderate-large effects). Participants who developed panic disorder, agoraphobia, GAD, or MDD had increases in neuroticism if the disorder was current at follow-up (moderate-large effects). Participants who developed MDD but were in remission by follow-up had a moderate increase in neuroticism. CONCLUSIONS: High neuroticism in young adulthood is either a true risk factor, or marker of risk, for first-onset anxiety and depressive disorders, as is low extraversion for agoraphobia. The current data suggest large neuroticism "state" effects for panic disorder, agoraphobia, and MDD, and moderate "scar" effects from MDD. Though many clinicians and researchers regard personality traits simply as "vulnerability" factors, longitudinal analyses suggest additional complexity.

Impact of adolescent complex regional pain syndrome on the psychopathology of young men ahead of military service: a retrospective cohort analysis of Korean conscription data.

BACKGROUND: The relationship between physical and psychopathological features in complex regional pain syndrome (CRPS) has been a subject of constant interest, but no data are available in adolescents. Therefore, we aimed to identify the factors associated with psychopathology in adolescents with CRPS ahead of military service. METHODS: We retrospectively reviewed all conscription examinees who had completed a Military Personality Inventory (MPI) during a period between February 2013 and December 2016. A total of 63 persons with a history of CRPS (19-years of age for all) were enrolled. Basic demographic and pain-related data were analyzed to examine their association with MPI results. The mean FGR score as well as the 8 subdomain scores were compared between those with pain duration at < 15 months (n = 30) versus ≥15 months (n = 33). Binary MPI results (normal-abnormal) were also compared between the two groups. RESULTS: In multivariate analysis, abnormal MPI was associated with pain duration, with an odds ratio (OR) at 1.05 for every 1-month increase (95% confidence interval (CI) 1.02-1.08; P = 0.002). Subjects with pain duration at ≥15 months have lower faking good response score (P < 0.001 vs. those with pain duration at < 15 months), and higher abnormal MPI result rate, faking bad response, inconsistency, anxiety, depression, somatization, paranoid, personality disorder cluster A, and personality disorder cluster B scores (P < 0.05). Pain duration was significantly associated with the MPI variables. CONCLUSIONS: Pain duration is associated with psychopathology in adolescents with CRPS. Psychopathologic features increased as the disease duration increased. A comprehensive understanding of time-dependent psychopathological factors could support the planning of multimodal approaches for managing adolescent CRPS.

Personality Profiles and Psychological Adjustment in Breast Cancer Patients.

Dispositional personality characteristics may play a role in psychosocial adjustment to any disease, including cancer. PURPOSE: The purpose of this study is to identify personality profiles in breast cancer patients and to determine whether these profiles are associated with psychological adjustment or psychopathology. METHODS: Participants were 109 women (mean age, 52.01) diagnosed with breast cancer. They completed the Millon Clinical Multiaxial Inventory-III (MCMI-III), the Life Orientation Test-Revised (LOT-R), the Satisfaction with Life Scale, and the Positive and Negative Affect Scales. RESULTS: The analysis revealed two different personality profiles: (a) one group, comprising 38.23% of the sample, was characterized by paranoid, negativistic, and dependent personality traits and was considered as a "vulnerable group"; and (b) another group (61.77%) was characterized by compulsive, histrionic, and narcissistic personality traits and was considered as a "psychologically adjusted group". The vulnerable group scored higher than the psychologically adjusted group on all clinical syndromes, with scores above 60 on the anxiety, somatoform, dysthymic, and bipolar scales (score on anxiety being above 75); in contrast, the psychologically adjusted group did not reach a base rate score of 60 on any of the clinical syndromes, showing no manifestations of psychopathology. Additionally, the vulnerable group scored lower than the psychologically adjusted group on optimism, life satisfaction, and positive affect, but higher on negative affect. CONCLUSIONS: The results suggest that personality traits could affect the psychological adjustment of breast cancer survivors. We discuss the implications of belonging to each group and highlight the importance of early identification of vulnerable women in order to facilitate clinical and psychological support.

The association between neurocognitive functioning and clinical features of borderline personality disorder

Objective: To investigate the relationship between neurocognitive profiles and clinical manifestations of borderline personality disorder (BPD). Methods: Forty-five patients diagnosed with BPD and 35 healthy volunteers were included in the study. The BPD group was evaluated with the Borderline Personality Inventory for dissociative, impulsivity and suicidal dimensions. The Verbal Memory Processes Test and the Cambridge Neurophysiological Assessment Battery were administered to both the BPD and healthy control groups. Results: BPD patients differed from controls in sustained attention, facial emotion recognition, and deteriorated verbal memory function. A model consisting of the Dissociative Experiences Scale - Taxon (DES-T), motor impulsivity and Scale for Suicidal Behavior scores explained 52% of the variance in Borderline Personality Inventory scores. It was detected that motor impulsivity, decision-making and recognizing sadness may significantly predict DES-T scores, and response inhibition and facial emotion recognition scores may significantly predict impulsivity. Conclusion: Our findings demonstrate that the disassociation, impulsivity, and suicidality dimensions are sufficient to represent the clinical manifestations of BPD, that they are related to neurocognitive differences, and that they interact with clinical features.

Psychosocial Outcomes of Donors Whose Recipients Died After Living Donor Liver Transplantation.

PURPOSE: Our aim was to investigate the psychosocial outcomes of the donors whose recipients died after living donor liver transplantation (LDLT). METHODS: Forty-one donors whose recipients died and 87 donors whose recipients were alive after LDLT at Inonu University Liver Transplantation Institute between 2012 and 2017 were included into the study. Demographic data form, Beck anxiety scale, Beck depression scale, Beck Hopelessness Scale, Posttraumatic Growth Inventory, Decision Regret Scale, Multidimensional Scale of Perceived Social Support, and general evaluation questionnaire (24 questions) were used in all donors by face to face questioning. In addition to the descriptive statistical analysis, chi-square and student's t tests were used to evaluate the differences between the groups. RESULTS: Recipient death after living donor liver transplantation is a factor that negatively increases the level of anxiety, depression, hopelessness levels, and repentance of donors, and adversely affects the psychological growth of the donors after donation experience. CONCLUSION: Regular follow-up of the donors should be done psychosocially in the postoperative period, especially the donors whose recipients have died should be followed up more frequently, and their support and treatment should be provided when needed. The donors should also be informed about the psychosocial implications of operative management and postoperative period. More studies are needed regarding the psychosocial problems of the donors.

A facet atlas: Visualizing networks that describe the blends, cores, and peripheries of personality structure.

We created a facet atlas that maps the interrelations between facet scales from 13 hierarchical personality inventories to provide a practically useful, transtheoretical description of lower-level personality traits. We generated this atlas by estimating a series of network models that visualize the correlations among 268 facet scales administered to the Eugene-Springfield Community Sample (Ns = 571-948). As expected, most facets contained a blend of content from multiple Big Five domains and were part of multiple Big Five networks. We identified core and peripheral facets for each Big Five domain. Results from this study resolve some inconsistencies in facet placement across instruments and highlight the complexity of personality structure relative to the constraints of traditional hierarchical models that impose simple structure. This facet atlas (also available as an online point-and-click app at tedschwaba.shinyapps.io/appdata/) provides a guide for researchers who wish to measure a domain with a limited set of facets as well as information about the core and periphery of each personality domain. To illustrate the value of a facet atlas in applied and theoretical settings, we examined the network structure of scales measuring impulsivity and tested structural hypotheses from the Big Five Aspect Scales inventory.

Study of the Correlation Between Multiple Chemical Sensitivity and Personality Using the Quick Environmental Exposure Sensitivity Inventory Questionnaire and the Temperament and Character Inventory.

OBJECTIVE: We conducted an analysis using the Quick Environmental Exposure Sensitivity Inventory to examine the correlation between multiple chemical sensitivity (MCS) and personality traits by using temperament and character inventory, and environmental exposures. METHODS: An anonymous questionnaire was distributed to 667 employees working at an IT manufacturing plant in Japan. Variables including chemically sensitive population (CSP), personality, and environmental chemical exposure were individually evaluated using U-test, chi-squared test, and correlation analyses. We also did covariance structure analysis to build a structural equation model. RESULTS: There was little direct impact of temperament on the CSP, while there was a significant impact of character on the CSP. Women were more likely to exhibit symptoms of CSP. CONCLUSION: MCS is correlated with personality, impacted more by character acquired later in life than innate temperament. There were sex differences in the incidence of MCS.

Psychometric Properties of the Brief Resilient Coping Scale in a Sample of Stable Severe Mental Disorder Patients.

The aim of this study was to analyze the psychometric properties of the Brief Resilient Coping Scale (BRCS). 57 stable severe mental disorder patients (42 men, 73.7%, and 15 women, 26.3%), ranging in age between 23 and 64 years, (M = 46.25; SD = 7.52) answered to the BRCS and the World Health Organization Quality of Life Assessment (WHOQOL-BREF). Descriptive analyses, estimations of internal consistency, and confirmatory factor analysis were conducted, and correlations between the BRCS and the WHOQOL-BREF were calculated. The factorial validity of the scale was tested using confirmatory factor analysis, with a single dimension of resilience. The BRCS showed acceptable internal consistency (alpha of .69). Correlations between the BRCS and WHOQOL-BREF were positive, r(PhH-R) = .42, r(PsH-R) = .40, r(SR-R) = .33, r(E-R) = .35, and significant (p < .01). In conclusion, the Spanish adaptation of the BRCS seems to be a reliable and valid measure of resilience in stable severe mental disorder patients.