Comparison of alternative models for personality disorders, II: 6-, 8- and 10-year follow-up.

BACKGROUND: Several conceptual models have been considered for the assessment of personality pathology in DSM-5. This study sought to extend our previous findings to compare the long-term predictive validity of three such models: the five-factor model (FFM), the schedule for nonadaptive and adaptive personality (SNAP), and DSM-IV personality disorders (PDs). METHOD: An inception cohort from the Collaborative Longitudinal Personality Disorder Study (CLPS) was followed for 10 years. Baseline data were used to predict long-term outcomes, including functioning, Axis I psychopathology, and medication use. RESULTS: Each model was significantly valid, predicting a host of important clinical outcomes. Lower-order elements of the FFM system were not more valid than higher-order factors, and DSM-IV diagnostic categories were less valid than dimensional symptom counts. Approaches that integrate normative traits and personality pathology proved to be most predictive, as the SNAP, a system that integrates normal and pathological traits, generally showed the largest validity coefficients overall, and the DSM-IV PD syndromes and FFM traits tended to provide substantial incremental information relative to one another. CONCLUSIONS: DSM-5 PD assessment should involve an integration of personality traits with characteristic features of PDs.

The association of personality disorders with the prospective 7-year course of anxiety disorders.

BACKGROUND: This study prospectively examined the natural clinical course of six anxiety disorders over 7 years of follow-up in individuals with personality disorders (PDs) and/or major depressive disorder. Rates of remission, relapse, new episode onset and chronicity of anxiety disorders were examined for specific associations with PDs. METHOD: Participants were 499 patients with anxiety disorders in the Collaborative Longitudinal Personality Disorders Study, who were assessed with structured interviews for psychiatric disorders at yearly intervals throughout 7 years of follow-up. These data were used to determine probabilities of changes in disorder status for social phobia (SP), generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), panic disorder and panic disorder with agoraphobia. RESULTS: Estimated remission rates for anxiety disorders in this study group ranged from 73% to 94%. For those patients who remitted from an anxiety disorder, relapse rates ranged from 34% to 67%. Rates for new episode onsets of anxiety disorders ranged from 3% to 17%. Specific PDs demonstrated associations with remission, relapse, new episode onsets and chronicity of anxiety disorders. Associations were identified between schizotypal PD with course of SP, PTSD and GAD; avoidant PD with course of SP and OCD; obsessive-compulsive PD with course of GAD, OCD, and agoraphobia; and borderline PD with course of OCD, GAD and panic with agoraphobia. CONCLUSIONS: Findings suggest that specific PD diagnoses have negative prognostic significance for the course of anxiety disorders underscoring the importance of assessing and considering PD diagnoses in patients with anxiety disorders.

Improvement in borderline personality disorder in relationship to age.

OBJECTIVE: It is commonly believed that some features of borderline personality disorder (BPD) improve as individuals reach their late 30s and 40s. This study examined age-related change in borderline criteria and functional impairment, testing the hypothesis that older age would be associated with relatively more improvement than younger age. METHOD: A total of 216 male and female participants with BPD were followed prospectively with yearly assessments over 6 years. RESULTS: Participants showed similar rates of improvement in borderline features regardless of age. A significant age by study year interaction showed functioning in older subjects to reverse direction and begin to decline in the latter part of the follow-up, in contrast to younger subjects who maintained or continued improvement over the 6 years. Despite the decline, functioning for the older subjects was comparable with or slightly better at year 6 than at year 1. CONCLUSION: Improvement in borderline features is not specific to the late 30s and 40s. There may be a reversal of improvement in functioning in some borderline patients in this older-age range.

Personality traits as prospective predictors of suicide attempts.

OBJECTIVE: To examine higher order personality factors of negative affectivity (NA) and disinhibition (DIS), as well as lower order facets of impulsivity, as prospective predictors of suicide attempts in a predominantly personality disordered sample. METHOD: Data were analyzed from 701 participants of the Collaborative Longitudinal Personality Disorders Study with available follow-up data for up to 7 years. Cox proportional hazards regression analyses was used to examine NA and DIS, and facets of impulsivity (e.g. urgency, lack of perseverance, lack of premeditation and sensation seeking), as prospective predictors of suicide attempts. RESULTS: NA, DIS and all facets of impulsivity except for sensation seeking were significant in univariate analyses. In multivariate models which included sex, childhood sexual abuse, course of major depressive disorder and substance use disorders, only NA and lack of premeditation remained significant in predicting suicide attempts. DIS and the remaining impulsivity facets were not significant. CONCLUSION: NA emerged as a stronger and more robust predictor of suicide attempts than DIS and impulsivity, and warrants greater attention in suicide risk assessment. Distinguishing between facets of impulsivity is important for clinical risk assessment.

Factor analysis of the DSM-III-R borderline personality disorder criteria in psychiatric inpatients.

OBJECTIVE: The goal of this study was to examine the factor structure of the DSM-III-R criteria for borderline personality disorder in young adult psychiatric inpatients. METHOD: The authors assessed 141 acutely ill inpatients with the Personality Disorder Examination, a semistructured diagnostic interview for DSM-III-R personality disorders. They used correlational analyses to examine the associations among the different criteria for borderline personality disorder and performed an exploratory factor analysis. RESULTS: Cronbach's coefficient alpha for the borderline personality disorder criteria was 0.69. A principal components factor analysis with a varimax rotation accounted for 57.2% of the variance and revealed three homogeneous factors. These factors were disturbed relatedness (unstable relationships, identity disturbance, and chronic emptiness); behavioral dysregulation (impulsivity and suicidal/self-mutilative behavior); and affective dysregulation (affective instability, inappropriate anger, and efforts to avoid abandonment). CONCLUSIONS: Exploratory factor analysis revealed three homogeneous components of borderline personality disorder that may represent personality, behavioral, and affective features central to the disorder. Recognition of these components may inform treatment plans.

Treatment utilization by patients with personality disorders.

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

Characteristics of effective therapists: further analyses of data from the National Institute of Mental Health Treatment of Depression Collaborative Research Program.

Analyses of the data of the National Institute of Mental Health-sponsored Treatment of Depression Collaborative Research Program have primarily examined the effects of types of treatment and patient characteristics on outcome, but scant attention has been directed toward evaluating the contributions of the therapist. With an aggregate of residualized therapeutic change scores of the 5 primary outcome measures for each patient at termination as an overall measure of improvement, an average therapeutic effectiveness measure was derived for each of the 28 therapists based on the outcome of the patients they saw in active treatment. The distribution of the therapists was divided into thirds, and comparisons indicate that more effective therapists are more psychological minded, eschew biological interventions (i.e., medication and electroconvulsive therapy) in their ordinary clinical practice, and expect outpatient treatment of depression to take longer than did moderately and less effective therapists.

When and how perfectionism impedes the brief treatment of depression: further analyses of the National Institute of Mental Health Treatment of Depression Collaborative Research Program.

Perfectionism has previously been identified as having a significant negative impact on therapeutic outcome at termination in the brief (16-week) treatment of depression (S. J. Blatt, D. M. Quinlan, P. A. Pilkonis, & T. Shea, 1995) as measured by the 5 primary outcome measures used in the National Institute of Mental Health Treatment of Depression Collaborative Research Program (TDCRP). The present analyses of other data from the TDCRP indicated that this impact of perfectionism on therapeutic outcome was also found in ratings by therapists, independent clinical evaluators, and the patients and that this effect persisted 18 months after termination. In addition, analyses of comprehensive, independent assessments made during the treatment process indicated that perfectionism began to impede therapeutic gain in approximately 2/3 of the sample, in the latter half of treatment, between the 9th and 12th sessions. Implications of these findings are discussed, including the possibility that more perfectionistic patients may be negatively impacted by anticipation of an arbitrary, externally imposed termination date.

Relation of therapeutic alliance and perfectionism to outcome in brief outpatient treatment of depression.

Prior analyses of the National Institute of Mental Health Treatment of Depression Collaborative Research Program demonstrated that perfectionism was negatively related to outcome, whereas both the patient's perception of the quality of the therapeutic relationship and the patient contribution to the therapeutic alliance were positively related to outcome across treatment conditions (S. J. Blatt, D. C. Zuroff, D. M. Quinlan, & P. A. Pilkonis, 1996; J. L. Krupnick et al., 1996). New analyses examining the relations among perfectionism, perceived relationship quality, and the therapeutic alliance demonstrated that (a) the patient contribution to the alliance and the perceived quality of the therapeutic relationship were independent predictors of outcome, (b) perfectionistic patients showed smaller increases in the Patient Alliance factor over the course of treatment, and (c) the negative relation between perfectionism and outcome was explained (mediated) by perfectionistic patients' failure to develop stronger therapeutic alliances.

Vulnerability to depression: reexamining state dependence and relative stability.

Treatment-related decreases in Dysfunctional Attitudes Scale (DAS; Weissman & Beck, 1978) scores have been interpreted as evidence that dysfunctional attitudes are state-dependent concomitants of depression. Data from the National Institute of Mental Health Treatment of Depression Collaborative Research Program were used to reexamine the stability of dysfunctional attitudes. Mean scores for Perfectionism, Need for Approval, and total DAS decreased after 16 weeks of treatment. However, test-retest correlations showed that the DAS variables displayed considerable relative stability. Structural equation models demonstrated that dysfunctional attitudes after treatment were significantly predicted by initial level of dysfunctional attitudes as well as by posttreatment depression. The relative stability of dysfunctional attitudes was even higher during the 18-month follow-up period. The results were consistent with Beck's (1967) and Blatt's (1974) theories of vulnerability.

Norm-of-reaction: definition and misinterpretation of animal research.

The development of a phenotype is due to an interaction of the genotype with the environment. Two terms have been used to describe the outcome of this interaction, the norm-of-reaction and the reaction range. The first represents the theoretically limitless distribution of the phenotypes that may be expressed by a given genotype. The reaction range implies an upper and lower limit for phenotype expression possible from a given genotype. A critical distinction between the reaction range and the norm-of-reaction is that the norm-of-reaction is a statement of the conceivable interactions found but does not imply any predictability other than that within the conditions previously tested experimentally, that is, the tails of a normal distribution are infinitely variable, whereas the concept of reaction range implies a limitation inherent in the genotype, that is, a finite range. Empirical support for the reaction-range concept is questionable. Animal studies cited in support of the reaction range have been inappropriately and incorrectly interpreted.

Avoidant personality disorder and social phobia: distinct enough to be separate disorders?

OBJECTIVE: Existing evidence from anxiety disorder research indicates that social phobics (SP) with avoidant personality disorder (AVPD) experience more anxiety and show more impairment than patients with SP alone. The purpose of this study was to examine whether in patients diagnosed with AVPD, the co-occurrence of SP adds to its severity. We hypothesized that the addition of SP will not add to the severity of AVPD alone. METHOD: Two groups of patients (AVPD=224; AVPD/SP=101) were compared at baseline and 2 years later on multiple demographic and clinical variables. RESULTS: Patients with AVPD and an additional diagnosis of SP differed little from patients with AVPD alone. CONCLUSION: These findings suggest that AVPD and SP may be alternative conceptualizations of the same disorder.

Treatment outcome of personality disorders.

OBJECTIVE: To review the treatment outcome of personality disorders. METHOD: A literature search of studies pertaining to personality disorder and outcome was conducted, and studies that focused primarily on Axis II were retained. Of these, naturalistic outcome studies were distinguished from those that addressed treatment outcome specifically. The treatment outcome studies were examined in terms of type of treatment intervention, dependent variables, and outcome. RESULTS: Contrary to contemporary assumptions about Axis II, a substantial number of treatment outcome studies were identified. Trends in the assumptions underlying psychosocial and pharmacologic approaches were identified on the basis of dependent variables. CONCLUSION: There is evidence that effective treatments exist to alleviate symptoms and reduce symptomatic behaviours that accompany personality disorders. What these results hold for the idea of remission from personality disorder is considered.

Correlates of suicide risk in adolescent inpatients who report a history of childhood abuse.

The study objective was to examine correlates of suicide risk in psychiatrically hospitalized adolescents with a reported history of childhood abuse. Predictors of suicide risk were examined in 74 subjects who reported a history of childhood abuse and 53 depressed subjects who did not report a history of childhood abuse. Subjects completed a battery of psychometrically well-established self-report instruments to assess childhood abuse, suicide risk, and internalizing and externalizing psychopathology. Correlational analyses showed that higher levels of depression, self-criticism, and hopelessness were significantly associated with suicide risk in both study groups and violence was significantly associated with suicide risk in the childhood abuse group. For the childhood abuse group, multiple regression analyses with seven predictor variables accounted for 54% of the variance in suicide risk; depression and alcohol problems made significant independent contributions, while violence and self-criticism were independent predictors at the trend level. For the depressed/nonabused group, multiple regression analyses with the seven predictor variables accounted for 60% of the variance in suicide risk; depression, hopelessness, and self-criticism were independent predictors. Our findings suggest that both internalizing (i.e., depression or self-criticism) and externalizing (i.e., violence or alcohol) factors predict suicide risk in adolescent inpatients who report childhood abuse. This profile appears different from the more internalizing pattern (i.e., depression, self-criticism, and hopelessness) observed for the depressed adolescent inpatients who reported no history of childhood abuse.

Stressful life events as predictors of functioning: findings from the collaborative longitudinal personality disorders study.

OBJECTIVE: Although much attention has been given to the effects of adverse childhood experiences on the development of personality disorders (PDs), we know far less about how recent life events influence the ongoing course of functioning. We examined the extent to which PD subjects differ in rates of life events and the extent to which life events impact psychosocial functioning. METHOD: A total of 633 subjects were drawn from the Collaborative Longitudinal Personality Disorders Study (CLPS), a multi-site study of four personality disorders--schizotypal (STPD), borderline (BPD), avoidant (AVPD), obsessive-compulsive (OCPD)--and a comparison group of major depressive disorders (MDD) without PD. RESULTS: Borderline personality disorder subjects reported significantly more total negative life events than other PDs or subjects with MDD. Negative events, especially interpersonal events, predicted decreased psychosocial functioning over time. CONCLUSION: Our findings indicate higher rates of negative events in subjects with more severe PDs and suggest that negative life events adversely impact multiple areas of psychosocial functioning.

Longitudinal diagnostic efficiency of DSM-IV criteria for obsessive-compulsive personality disorder: a 2-year prospective study.

OBJECTIVE: To examine the longitudinal diagnostic efficiency of the DSM-IV criteria for obsessive-compulsive personality disorder (OCPD). METHOD: At baseline, criteria and diagnoses were determined using diagnostic interviews, and blinded assessments were performed 24 months later with 550 participants. Diagnostic efficiency indices (conditional probabilities, total predictive power, and kappa) were calculated for each criterion determined at baseline, using the independent OCPD diagnosis at follow-up as the standard. RESULTS: Longitudinal diagnostic efficiencies for the OCPD criteria varied; findings suggested the overall predictive utility of 'preoccupied with details', 'rigid and stubborn', and 'reluctant to delegate'. CONCLUSION: These findings suggest the predictive validity of three cognitive-interpersonal OCPD criteria.

Internal consistency, intercriterion overlap and diagnostic efficiency of criteria sets for DSM-IV schizotypal, borderline, avoidant and obsessive-compulsive personality disorders.

OBJECTIVE: To evaluate performance characteristics of DSM-IV Personality Disorders (PDs) criteria. METHOD: Six hundred and sixty-eight adults recruited for the Collaborative Longitudinal Personality Disorders Study (CLPS) were assessed with diagnostic interviews. RESULTS: Within-category inter-relatedness was evaluated by Cronbach's alpha and median intercriterion correlations (MIC). Cronbach's alpha ranged from 0.47 to 0.87 (median=0.71); seven of the 10 PDs had alphas greater than 0.70. Between-category criterion overlap was evaluated by "inter-category" intercriterion correlations between all PD pairs (ICMIC). ICMIC values (median=0.08) were lower than MIC values (median=0.23). Diagnostic efficiency statistics (sensitivity, specificity, positive predictive power and negative predictive power were calculated for schizotypal, borderline, avoidant and obsessive-compulsive PDs. CONCLUSION: DSM-IV PD criteria sets have some convergent validity and discriminant validity: criteria for individual PDs correlate better with each other than with criteria for other PDs. Diagnostic efficiency statistics provide guidance regarding usefulness of criteria for inclusion or exclusion.