A bifactor model of personality organization in adolescence: the validity of a brief screening measure assessing severity and core domains of functioning.

BACKGROUND: Both the latest edition of the DSM-5 as well as the new ICD-11 have established a new focus in the diagnosis of personality disorders: the assessment of personality functioning. This recent shift in focus converges with long-standing psychodynamic conceptualizations of personality pathology, particularly Kernberg's object relations model. Although a significant amount of research supports these models in adults, much less is known about the validity of these frameworks in youth. Considering the paucity of brief measures of personality functioning in adolescents, the current study aimed to develop and investigate the validity of the Inventory of Personality Organization for Adolescents-Short Form, a theoretically-informed measure assessing severity and core domains of functioning in adolescents. METHODS: A total sample of N = 525 adolescents aged 13 to 19 years were recruited through a community University-Health Psychology Clinic as current patients (n = 94) or who responded to an online research call (n = 431). RESULTS: Results indicate that a bifactor model provided the best fit to the data and consisted of a general factor reflecting core self-other functioning and three specific factors, representing additional dimensions of personality organization. CONCLUSIONS: A brief 15-item version of the IPO-A was successfully derived for time-efficient screening of personality pathology in youth. Similarities with the ICD-11 framework are discussed.

No treatment as the prescription of choice.

As part of each evaluation, the clinician must decide whether or not a psychiatric treatment is indicated. It is unfortunate that there is little available research to aid in this decision, and it has not received much attention in the clinical literature. In actual practice, therapists tend to recommend treatment almost automatically and without a careful consideration of its necessity or possible harmful effects. The research methodology and problems is defining those patients who are better off without psychiatric treatment is discussed. This group is categorized into negative responders and nonresponders and spontaneous improvers. A set of preliminary criteria for no treatment and clinical examples are provided.

Psychotherapy of depression. Implications for reform of the health care system.

This article reviews the empirical evidence supporting the role of psychotherapy and psychosocial interventions in the treatment of patients with depression. Treatment models and the evidence for their effectiveness in the acute-and maintenance-treatment phases are reviewed. Whereas the sophistication of research designs and data analysis for the study of psychotherapy have substantially improved, the review highlights current gaps in our knowledge. Most important for reform of the health care system is the need for studies of efficacy to lead to large-scale investigations of effectiveness.

Diagnostic efficiency and DSM-III.

This study critiques and extends the DSM-III use of fixed and explicit criteria by applying principles and statistics common within actuarial decision theory (eg, conditional probabilities). The value and limitations of sensitivity and specificity rates are discussed and compared with an interesting but rarely used statistic, positive predictive power. The statistics and analyses provided herein also provide an empirical method for developing diagnostic criteria and determining when and how the DSM-III cutoff points might be adjusted, recognize the importance of base rates and utilities to efficient diagnosis, and provide an explicit, quantitative means by which to make optimal differential diagnoses and to make use of the overlap among psychiatric diagnoses. The issues are illustrated in the differential diagnosis of the Borderline Personality Disorder, but they have a relevance to the development and application of the other DSM-III diagnoses.

Inpatient family intervention: a randomized clinical trial. II. Results at hospital discharge.

Although family intervention is practiced in most psychiatric hospitals, to our knowledge, no adequately controlled studies of its efficacy exist. This study was designed to answer, in part, the question of the relative efficacy of hospitalization with family intervention as compared with hospitalization without family intervention for patients (1) with major psychiatric disorders, (2) in need of hospital treatment, and (3) for whom both treatments are judged clinically feasible. This article compares treatment results at the time of hospital discharge for 169 patients randomly assigned to the inpatient Family Intervention or comparison conditions. Inpatient Family Intervention had greater efficacy than the comparison treatment, mostly attributable to its effect on female patients, especially those patients (and their families) with affective disorder.

A controlled evaluation of inpatient family intervention. I. Preliminary results of the six-month follow-up.

Although family intervention is practiced in most psychiatric hospitals, there are no adequately controlled studies of its efficacy. This study was designed to answer, in part, the following question: What is the relative efficacy of hospitalization with family intervention as compared with hospitalization without family intervention for patients with major psychiatric disorders who are in need of hospital treatment and for whom both treatments are judged clinically feasible? This is our first report, presenting preliminary data on six-month follow-up for the first three quarters of the total sample of 144 patients (80 with schizophrenic disorder and 64 with major affective disorder).

DSM-III and family therapy.

In its current form, DSM-III is of only limited value to family therapists. The authors suggest several innovations that might render future nomenclatures more useful. Axis II ratings that are interpersonal and dimensional, rather than individual and categorical, might provide important additional data for predicting and planning a family intervention. Several available family classifications suggest ways in which to derive an axis VI rating of family functioning. The authors address a number of conceptual issues that make family classification especially interesting and difficult.

Subtypes of self-injurious patients with borderline personality disorder.

Twenty-seven female inpatients with borderline personality disorder were assigned to two groups on the basis of whether they did (N = 14) or did not (N = 13) report experiencing pain during self-injurious episodes. Ratings of depression, anxiety, impulsiveness, dissociation, and trauma symptoms were higher in the women who did not experience pain while injuring themselves, as were the number of suicide attempts and the prevalence of childhood sexual abuse.

Assessing borderline personality disorder with self-report, clinical interview, or semistructured interview.

The authors compared three methods of assessing borderline personality disorders. Test-retest reliability for the self-report Personality Diagnostic Questionnaire was adequate and compared favorably with the interrater reliability of the DSM-III-oriented clinical interview and the semistructured research interview. The overall prevalence of personality disorders scored on the questionnaire was similar to that generated by the clinical interview. The specificity and sensitivity of the questionnaire for the diagnosis of borderline personality disorder were slightly higher than 60%, which suggests that it may be a useful and economical instrument for identifying patients with borderline personality disorder.

History of suicidal behavior in depressed borderline inpatients.

The DSM-III definition of borderline personality disorder emphasizes affective symptoms. The authors hypothesized that depressed patients with borderline personality disorder would be more likely to be suicidal than those without this diagnosis. Of 53 inpatients treated for depression, 46 manifested personality disorders; borderline personality disorder was the most prevalent axis II diagnosis. That borderline patients had more complicated courses than the other depressed patients was evidenced by their histories of suicidal behavior. Most patients diagnosed as having borderline personality disorder continued to fulfill criteria for this diagnosis even when suicide attempts were excluded as a diagnostic criterion.

Reliability of criteria for borderline personality disorder: a comparison of DSM-III and the Diagnostic Interview for Borderline Patients.

The authors compared the reliability of two methods of distinguishing borderline personality disorder--DSM-III and the Diagnostic Interview for Borderline Patients. The reference group, outpatients with other personality disorders and without major axis I pathology, was more difficult to distinguish from the patients with borderline personality disorder than such groups used in previous samples. The sensitivity and specificity of the Diagnostic Interview for Borderline Patients were calculated, with DSM-III used as a criterion. The findings confirm considerable overlap between borderline and schizotypal personality disorders, more impairment in functioning in borderline patients than in those with other personality disorders, and the high reliability with which borderline personality disorder can be diagnosed.

A randomized clinical trial of inpatient family intervention, III: Effects at 6-month and 18-month follow-ups.

This paper focuses on the follow-up results of a randomized clinical trial of inpatient family intervention (IFI) that emphasized psychoeducation. Results for the sample of 169 psychiatric patients suggested that adding family treatment to standard hospital treatment was effective; however, the statistical interactions indicated that this therapeutic effect was restricted to female patients with schizophrenia or major affective disorder. The effect of family treatment on male patients with these diagnoses was minimal or slightly negative. In a group of patients with other diagnoses, the Treatment by Sex effect was reversed: male patients did better with the family treatment.

Affective and character pathology of suicidal adolescent and young adult inpatients.

Psychiatric diagnoses and severity of suicide attempts were compared between adolescents (14-19 years) and young adults (20-35 years) with depressed mood hospitalized following a suicide attempt. The depressive disorders manifested by the two age groups, determined by semi-structured interview, were basically the same. The degree of lethality and frequency of suicide attempts were approximately equal in the two groups. Adolescents in this investigation who manifested the same behaviors as older patients were diagnosable by the same criteria.

A randomized clinical trial of inpatient family intervention. IV. Followup results for subjects with schizophrenia.

This is the last of a series of four papers, here focussing on schizophrenia, which report followup data up to 18 months from a randomized clinical trial of a psychoeducational family intervention (IFI), which was added to medication and limited to the inpatient phase of treatment, after which post-hospital care was not controlled. Our data suggested that patients with poor prehospital functioning (i.e., the chronic patients) may benefit from inpatient family intervention, but this therapeutic effect appears to be limited to females and does not appear until 18 months postadmission. Families of patients with schizophrenia also show benefit from having received IFI, the effect is seen earlier than with the patients, and is associated with achieving the goals of IFI. The results in the IFI group could not be accounted for by improved post-hospital medication compliance, but they may be related to this group's greater tendency to obtain further family treatment after discharge.

Gender and schizophrenia outcome: a clinical trial of an inpatient family intervention.

Several studies document sex differences in premorbid and intermorbid role functioning, showing less functional deficit among females. The specific nature of sex differences in role functioning is still poorly understood. The purpose of the present study was to investigate sex differences in symptomatology and role functioning in a sample of 92 inpatients hospitalized for an episode of DSM-III-diagnosed schizophrenic disorder. Patients were randomized at hospital admission to either of two treatment conditions: (1) multimodal hospital treatment with the addition of an inpatient family intervention (IFI) or (2) multimodal hospital treatment without IFI. Results indicated (1) sex differences in levels of substance abuse and antisocial behavior (worse for males both at admission and followup)--dimensions of psychopathology unrelated to the core features of schizophrenia; (2) superior family and occupational functioning in females at followup; and (3) superior clinical response of females to IFI. Data on family response to IFI suggest some ameliorative effects of IFI on critical family attitudes toward female patients as well as greater family compliance with IFI treatment among the families of females. Sex differences in intermorbid family and occupational functioning and response to a family-based psychosocial intervention are discussed in light of data on rejecting family attitudes toward the patient and sex differences in symptomatology. The possible influence of sex-differentiated social role demands on response to IFI is also discussed.

Introduction to special section: comorbidity and treatment implications.

This article initiates the special section on comorbidity and treatment implications. The presence of comorbidity is recognized, the multiple meanings of comorbidity are mentioned, and an invitation for much-needed research on comorbidity and related treatment is extended.

Comorbidity and treatment planning: summary and future directions.

This summary blends the commentaries from the 6 articles in the special section on comorbidity. Included is a discussion of various definitions of comorbidity, the merits and demerits of a hierarchical diagnostic system, and consideration of the extent, patterning, and nature of comorbidity. Directive comments with reference to future intervention planning mention both assessment (distinguishing overlapping constructs) and treatment (sequencing and treatment manuals) issues.

Personality pathology among married adults with bipolar disorder.

The comorbidity of DSM-III-R axis II personality disorders in patients with bipolar disorder has received less attention than for unipolar depression perhaps because of the potential confounding of state vs. trait qualities. The current study took steps to separate pathological traits of personality from behaviors evidenced during discrete affective episodes in a sample of married, outpatient bipolar patients. Data indicated that 22% of our patients met criteria for a categorical diagnosis of personality disorder. Axis II pathology as represented by both categorical and dimensional scores was associated with increased psychiatric symptoms during subsequent treatment and poorer social adjustment.

A randomized clinical trial of inpatient family intervention. V. Results for affective disorders.

This paper reports the results at follow-up of a randomized clinical trial of combining family intervention with drug treatment during hospitalization for patients with affective disorder. The results suggest that female bipolar patients and their families benefited from family intervention, whereas unipolar patients and families did not. Patient outcome was positively correlated with the achievement of the goals of family intervention.

Childhood antisocial behaviors as predictors of psychotic symptoms and DSM-III-R borderline criteria among inpatients with borderline personality disorder.

Structured clinical interviews of 107 female inpatients diagnosed with borderline personality disorder (BPD) were used to determine whether antisocial personality disorder (APD) diagnostic criteria evident prior to age 15 could be used to predict current Axis I and Axis II psychopathology. Diagnostic information was gathered using the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) and the Structured Clinical Interview for DSM-III-R-Patient Version (SCID-P). Childhood APD criteria were subjected to principal-components analysis, and three factors--rule-breaking, assault, and sadism--emerged. The severity of the childhood APD criteria was related to psychotic symptoms, as well as to the unstable relationships and labile affect BPD criteria and the current overall severity of BPD criteria. Sadism predicted psychotic symptoms and BPD severity, while rule-breaking predicted unstable relationships and BPD severity. Childhood APD severity also had a larger effect on BPD severity than on psychotic symptoms. Possible explanations for these findings are explored and discussed.