Association Between Attachment Patterns and Personality Disorders: A Multimethod Multi-Informant Study Using a Clinical Sample.

ABSTRACT: We investigated the association between personality disorders (PDs) and attachment patterns, and examined the construct validity of attachment patterns against adaptive functioning. We used a multimeasure multi-informant approach, which allowed us to disentangle the effects of the methods and to examine the utility of the various methods for measuring these constructs. The participants included 80 clinicians and 170 clinical outpatients, recruited via convenience sampling. Results showed that secure attachment was positively associated with adaptive functioning, whereas insecure patterns were negatively associated with adaptive functioning. Both categorical and dimensional PD diagnoses were associated with insecure attachment patterns. However, after controlling for comorbidity among the PD diagnoses, only some findings remained significant, most notably the association between borderline PD and the clinicians' assessment of preoccupied and incoherent/disorganized attachment, and the patients' self-reported attachment anxiety. Our findings underscore the importance of controlling for comorbidity in examining the associations between attachment patterns and PDs.

Unpacking childhood experiences of abuse: Can clinicians identify their patients' History of Abuse?

Emotional, physical and sexual abuse, have been consistently linked to mental health problems in adults. Previous research found that mental health providers rarely ask their patients about their childhood experiences of abuse. No study to date has examined the convergence of clinicians' and patients' reports of childhood abuse. The current study applied a multi-method, multi-informant approach to explore the concordance between patients' reports of childhood experiences of abuse and clinicians' identification of their patients' history of abuse. Assessment of an independent interviewer was included. A convenience sample of clinicians (N = 80) and their patients (N = 170) in mental health clinics in care-as-usual settings participated in the study. To assess the history of abuse clinicians and patients completed the Clinical Data Form, patients additionally completed the Childhood Trauma Questionnaire. Independent interviewer completed the Familial Experiences Interview. Findings show that across all informants, exposure to emotional abuse was most prevalent, followed by physical abuse and least prevalent was sexual abuse. Additionally, clinicians reported lower prevalence of physical and sexual abuse among their patients as compared with the patient and independent interviewer's reports. Moderate to strong correlations were observed between clinicians, patients and independent interviewer reports of emotional, physical and sexual childhood abuse. Moreover, the severity of the patient's history of abuse was related to greater accuracy in clinicians' reports. Clinicians are advised to collect explicit information regarding childhood abuse through interviews or valid measures. Clinicians should pay special attention when assessing patients with moderate severity of childhood abuse since they are frequently under-identified.

Reliability of DSM and empirically derived prototype diagnosis for mood, anxiety and personality disorders.

BACKGROUND: Prominent psychiatric diagnostic systems such as the DSM-IV and ICD-10 have shown low reliability in clinical practice. An alternative approach to classification of psychiatric disorders is prototype matching. In the current study, we examined reliability of assessing mood, anxiety and personality disorders using a multi-method multi informant approach. More specifically, we examined diagnosis made by treating clinician and independent expert clinical interviewer, using three different diagnostic systems (DSM symptom count, DSM-IV prototype diagnosis and empirically derived prototype diagnosis). METHODS: A convenience sample of clinicians (N = 80) and patients (N = 170) from eight community mental health clinics in Israel participated in the study. RESULTS: Our findings show fair to excellent interrater reliability for prototype dimensional diagnostic systems (ranged from 0.40 to 0.79) for most mood and anxiety disorders examined. Overall, dimensional diagnostic systems, yielded better interrater reliability for mood, anxiety and personality disorders, as compared with categorical diagnosis. There were no significant differences between dimensional systems. CONCLUSIONS: Our findings provide further support to the advantages of dimensional over categorical models in increasing reliability.

Agreement Among Clinician, Patient, and Independent Interviewer Ratings of Adaptive Functioning.

We examined the interrater reliability and diagnostic efficiency of clinician report (both the treating clinician and independent expert clinical interviewer) and patient self-report of clinically meaningful information pertaining to adaptive functioning. A convenience sample of clinicians (N = 80) and patients (N = 170) from eight community mental health clinics in Israel participated in the study. Our findings suggest that clinicians overall reliably report on adaptive functioning of patients (overall correct classification rates range, 0.74-0.98). Yet, in some areas, they may fail to collect necessary information such as self-mutilation history, loss of job in the past 5 years, and adult physical abuse. The patterns of higher versus lower diagnostic efficiency suggest that both treating clinicians and independent clinician interviewers tend to make judgments conservatively, essentially sacrificing sensitivity for specificity, not diagnosing events unless they were certain, thus maximizing false-negatives and minimizing false-positives.

Assessment of clinical information: Comparison of the validity of a Structured Clinical Interview (the SCID) and the Clinical Diagnostic Interview.

Adaptive functioning is a key aspect of psychiatric diagnosis and assessment in research and practice. This study compared adaptive functioning validity ratings from Structured Clinical Interviews (SCIDs, symptom-focused structured diagnostic interviews), and Clinical Diagnostic Interviews (CDIs, systematic diagnostic interviews modeling naturalistic clinical interactions focusing on relational narratives). Two hundred forty-five patients (interviewed by two independent interviewers) and their interviewers completed the Clinical Data Form which assesses adaptive functioning and clinical information. Both interviews converged strongly with patient-reports, with no significant differences in validity of the interviews in measuring global and specific domains of adaptive functioning variables. Findings suggest that CDIs provide adaptive functioning data comparable to SCIDs (often considered "gold standard" for assessment but difficult to use in practice) and have important implications for bridging the research-practice gap. By incorporating clinicians' everyday methods, CDIs yield information that is psychometrically sound for empirical investigation, diagnostically practical, and clinically meaningful and valid.

Personality constellations of adolescents with histories of traumatic parental separations.

Consistent with attachment theory and a developmental psychopathology framework, a growing body of research suggests that traumatic parental separations may lead to unique pathways of personality adaptation and maladaptation. The present study both examined personality characteristics and identified personality subtypes of adolescents with histories of traumatic separations. Randomly selected psychologists and psychiatrists provided data on 236 adolescents with histories of traumatic separations using a personality pathology instrument designed for use by clinically experienced observers, the Shedler-Westen Assessment Procedure. Using a Q factor analysis, five distinct personality subtypes were identified as follows: internalizing/avoidant, psychopathic, resilient, impulsive dysregulated, and immature dysregulated. Initial support for the validity of the subtypes was established on the basis of axis I and axis II pathology, adaptive functioning, developmental history, and family history variables. The personality subtypes demonstrated substantial incremental validity in predicting adaptive functioning, above and beyond demographic variables and histories of other traumatic experiences.

Attachment, social cognition, and posttraumatic stress symptoms in a traumatized, urban population: evidence for the mediating role of object relations.

Research has linked multiple risk and resiliency factors to developing posttraumatic stress disorder (PTSD). One potentially important construct for understanding connections between trauma and PTSD is attachment. Although relationships between attachment and risk for PTSD have been described theoretically, limited research has addressed these relationships empirically. Furthermore, aspects of object relations overlap with attachment and PTSD, but have not been adequately incorporated in empirical research. One proposed pathway between attachment and PTSD involves the mediating role of object relations, particularly views of self and others. Present data were from a larger study investigating environmental and genetic risk factors for PTSD in an impoverished, primarily African American sample seeking care at a public urban hospital. Correlations indicated that adult attachment (with the exception of dismissing) and object relations relate to childhood traumas, (|r|s = .19-.29), adult traumas (|r|s = .14-.20), and self-reported PTSD symptoms (|r|s = .20-.36). Analyses also found support for mediational roles of object relations in relationships between attachment and PTSD symptoms (Model R(2) range = .136-.160). These data have theoretical, clinical, and research implications for understanding how particular aspects of attachment, specifically its effects on object relations, may protect against or predispose one to develop PTSD.

Identity disturbance in adolescence: associations with borderline personality disorder.

Although establishing a coherent identity is often viewed as a normative developmental task of adolescence, an important question is whether forms of identity disturbance seen in adult personality disorders can also be distinguished in adolescents. If so, such disturbances would constitute an essential target for research and clinical interventions. The goal of this study is to investigate the nature of identity disturbance in an adolescent clinical sample and to explore its links with personality pathology, particularly borderline personality disorder. A national random sample of 139 psychiatrists and clinical psychologists completed a battery of instruments on a randomly selected adolescent patient in their care, including measures of Axis II symptoms and the Identity Disturbance Questionnaire-Adolescent Version, an instrument designed for clinically experienced observers that assesses a wide range of manifestations of potential identity disturbance among adolescents. Factor analysis of the Identity Disturbance Questionnaire--Adolescent Version yielded four clinically and conceptually coherent factors that resembled dimensions previously identified in adults: lack of normative commitment, role absorption, painful incoherence, and lack of consistency. As in adults, identity disturbance in adolescents is a clinically meaningful, multidimensional construct exhibiting significant relationships with different forms of severe personality pathology, most notably borderline personality disorder. As such, identity disturbance can be a manifestation of psychopathology above and beyond the typical Sturm und Drang (storm and stress) of adolescence.

Association between childhood maltreatment and adult emotional dysregulation in a low-income, urban, African American sample: moderation by oxytocin receptor gene.

The ability to effectively regulate emotions and a secure attachment style are critical for maintaining mental health across the life span. The experience of childhood maltreatment interferes with normal development of emotional regulation and dramatically increases risk for a wide range of psychiatric disorders in adulthood. The central nervous system oxytocin systems are critically involved in mediating social attachment and buffering psychophysiological responses to stress. We therefore investigated the impact of childhood maltreatment and an oxytocin receptor (OXTR) single nucleotide polymorphism (rs53576) and their interaction on emotional dysregulation and attachment style in adulthood in a sample of low-income, African American men and women recruited from primary care clinics of an urban, public hospital. Consistent with prior research, we found that the severity of childhood maltreatment was associated with increased levels of emotional dysregulation in adulthood. Childhood maltreatment was also positively associated with ratings of disorganized/unresolved adult attachment style and negatively associated with ratings of secure adult attachment style. There was no direct association between rs53576 and emotional dysregulation or ratings of adult attachment style. However, there were significant interactions between rs53576 and childhood maltreatment in predicting level of adult emotional dysregulation and attachment style. Specifically, G/G genotype carriers were at risk for increased emotional dysregulation when exposed to three or more categories of childhood abuse. In addition, G/G genotype carriers exhibited enhanced disorganized adult attachment style when exposed to severe childhood abuse compared to A/A and A/G carriers. Our findings suggest that A allele carriers of OXTR rs53576 are resilient against the effects of severe childhood adversity, by protection against emotional dysregulation and disorganized attachment.

Personality subtypes in adolescent and adult children of alcoholics: a two-part study.

The authors conducted two studies to identify and to validate potential personality subtypes in the adolescent and adult children of alcoholics. As part of a broader NIMH-funded study, randomly selected psychologists and psychiatrists provided personality data on adolescent (n = 208) or adult (n = 349) children of alcoholics using a Q-sort procedure (Shedler-Westen Assessment Procedure [SWAP]-II-A for adolescents and SWAP-II for adults), which were subjected to a cluster-analytic procedure, Q-factor analysis. Q-factor analysis yielded five personality subtypes in both groups. Despite the different samples and age groups, four of the personality subtypes were highly similar, including externalizing, inhibited, emotionally dysregulated, and high-functioning. Providing initial data on their validity, the subtypes differed on axis I and II pathology, adaptive functioning, and developmental and family history variables. These findings show heterogeneity among children of alcoholics and suggest the importance of addressing personality subtypes for research and practice in treating adolescent and adult children of alcoholics.

Personality subtypes of adolescents who attempt suicide.

Research suggests that personality pathology is shared among a considerable portion of adolescents presenting suicidal behavior. Furthermore, heterogeneity of personality within this population suggests a need to tease apart different types of attempters. The goal of this study was to identify the personality subtypes of adolescents who attempt suicide. We analyzed data on 266 adolescents, ages 13 to 18 years, with a history of at least one suicide attempt who were selected by treating clinicians for having at least some degree of personality problems. We used a Q-factor analysis to identify subtypes based on the Shedler-Westen Assessment Procedure-II for Adolescents (a 200-item measure of personality pathology used by clinically experienced observers). We derived six subtypes: Externalizing, Internalizing, Emotionally dysregulated, High functioning, Narcissistic, and Immature. The subtypes differed on measures of adaptive functioning, axis I and II pathology, and etiology. Adolescents who attempt suicide constitute a heterogeneous group, and they vary meaningfully on a measure of personality pathology. Interventions targeting suicidal behaviors in adolescents should consider individual differences.

Personalities of adults with traumatic childhood separations.

OBJECTIVES: This study examined personality characteristics and identified personality subtypes of adults with childhood histories of traumatic separations from a parent. Previous work from attachment theory and developmental psychopathology suggests that distinct developmental trajectories might lead to different styles of personality adaptation after an attachment disruption. design: Randomly selected psychologists and psychiatrists provided data on 203 adults with histories of traumatic separations using a personality pathology instrument designed for use by clinically experienced observers, the Shedler-Westen Assessment Procedure (SWAP-II). RESULTS: Using a Q-factor analysis, 5 distinct personality subtypes were identified: internalizing/avoidant, psychopathic, emotionally dysregulated, hostile/paranoid, and resilient. Initial support for the validity of the subtypes was established, based on Axis I and Axis II pathology, adaptive functioning, developmental history, and family history variables. CONCLUSIONS: Both therapeutic interventions and case formulation might be strengthened by considering an individual's personality features and match to one of the identified subtypes.

Prototype Personality Diagnosis in Clinical Practice: A Viable Alternative for DSM-V and ICD-11.

Several studies suggest that a prototype matching approach yields diagnoses of comparable validity to the more complex diagnostic algorithms outlined in DSM-IV. Furthermore, clinicians prefer prototype diagnosis of personality disorders (PDs) to the current categorical diagnostic system or alternative dimensional methods. An important extension of this work is to investigate the degree to which clinicians are able to make prototype diagnoses reliably. The aim of this study is to assess the inter-rater reliability of a prototype matching approach to personality diagnosis in clinical practice. Using prototypes derived empirically in prior research, outpatient clinicians diagnosed patients' personality after an initial evaluation period. External evaluators independently diagnosed the same patients after watching videotapes of the same clinical hours. Inter-rater reliability for prototype diagnosis was high, with a median r = .72. Cross-correlations between disorders were low, with a median r = .01. Clinicians and clinically trained independent observers can assess complex personality constellations with high reliability using a simple prototype matching procedure, even with prototypes that are relatively unfamiliar to them. In light of its demonstrated reliability, efficiency, and versatility, prototype diagnosis appears to be a viable system for DSM-V and ICD-11 with exceptional utility for research and clinical practice.

Personality subtypes in patients with panic disorder.

OBJECTIVE: This study examined personality subtypes of adults diagnosed with panic disorder (PD). METHODS: As part of a National Institute of Mental Health-funded study on personality in a clinical population, randomly selected psychologists and psychiatrists used a Q-sort instrument to describe 96 adults diagnosed with PD. RESULTS: Q-factor analysis yielded 4 personality subtypes: high functioning, emotionally dysregulated, inhibited/avoidant, and somatizing. Within the sample, the subtypes differed on Axis I and II pathology, adaptive functioning, and developmental and family history variables. Personality constellations in the sample showed substantial incremental validity in predicting adaptive functioning and treatment response above and beyond the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I diagnoses. CONCLUSIONS: These distinctions may elucidate the high rates of comorbidity among patients with PD and are important in understanding treatment choice and outcome.

Personality subtypes in disruptive adolescent males.

This study examined whether personality differences might account for meaningful heterogeneity within and across DSM-IV diagnostic categories for disruptive adolescent boys. In a broader study of personality pathology in adolescence, a national sample of 293 clinicians completed the Shedler-Westen Assessment Procedure 200-A on randomly selected outpatients aged 14 to 18 in their care. Of 138 boys in the sample, 71 had a diagnosis of Disruptive Behavior Disorders or a history of arrests. Q-factor analysis identified 3 personality subtypes within this subsample: psychopathic (n = 28), social outcast (n = 22), and impulsive delinquent (n = 17). The subtypes differed on external criterion variables indicative of a valid taxonomic distinction, notably personality ratings, clinician-report child behavior checklist subscale scores, and etiologic variables. Personality subtypes converged with subtypes of delinquent boys identified by longitudinal research, and they showed substantial incremental validity in predicting adaptive functioning beyond Disruptive Behavior Disorders diagnoses. Results suggest that dimensional personality assessment in disruptive/delinquent adolescent boys provides information beyond existing diagnoses that may prove useful in prevention, clinical conceptualization, and treatment.

Personality subtypes of suicidal adults.

Research into personality factors related to suicidality suggests substantial variability among suicide attempters. A potentially useful approach that accounts for this complexity is personality subtyping. As part of a large sample looking at personality pathology, this study used Q-factor analysis to identify subtypes of 311 adult suicide attempters using Shedler-Westen Assessment Procedure-II personality profiles. Identified subtypes included internalizing, emotionally dysregulated, dependent, hostile-isolated, psychopathic, and anxious somatizing. Subtypes differed in hypothesized ways on criterion variables that address their construct validity, including adaptive functioning, Axis I and II comorbidity, and etiology-related variables (e.g., history of abuse). Furthermore, dimensional ratings of the subtypes predicted adaptive functioning above DSM-based diagnoses and symptoms.

Validity and clinical utility of DSM and empirically derived prototype diagnosis for personality disorders in predicting adaptive functioning.

Prototype matching, which involves comparing a patient clinical presentation with a prototype description of the disorder addresses some of the clinical limitations of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases symptom-count approach. Here, we investigated the validity and clinical utility of three diagnostic systems in predicting patient adaptive functioning using a multimethod multi-informant approach. Specifically, we compared a prototype matching approach based on DSM criteria, an empirically derived prototype matching approach, and DSM symptom count diagnostic systems. A convenience sample of clinicians (N = 80) and patients (N = 170) participated in the study. We imposed minimal exclusion criteria for patient participation to maximize generalizability. Clinicians completed assessment of their active patients using two prototype matching diagnoses, one based on DSM and another that was empirically derived. Independent interviewers completed the Structured Clinical Interview to provide DSM symptom count. Patient global composite assessment of adaptive functioning, rated across the clinician, patient self-report, and independent interviewer, served as outcome variable. Prototype diagnosis for personality disorders, both one that is based on DSM criteria and one that was empirically derived, demonstrates some incremental validity over and above the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition symptom count, in predicting patient's adaptive functioning. Specifically, avoidant personality disorder prototype diagnosis significantly contributed to prediction of adaptive functioning. Furthermore, clinicians rated the prototype-matching approach as more useful in clinical practice compared with the current DSM-IV categorical approach. Using a dimensional approach, which is based on prototype matching that also preserves the advantages of categorical system offers a valid and efficient approach to psychiatric assessment for personality disorders. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Personality subtypes in adolescents with eating disorders: validation of a classification approach.

BACKGROUND: Research has identified three personality subtypes in adults with eating disorders (EDs): a high-functioning, an undercontrolled, and an overcontrolled group. The current study investigated whether similar personality prototypes exist in adolescents with EDs, and whether these personality prototypes show relationships to external correlates indicative of diagnostic validity. METHODS: Experienced clinicians from an adolescent practice-research network provided data on ED symptoms, DSM-IV comorbidity, personality pathology, and family and developmental history for 120 adolescent patients with EDs. RESULTS: Consistent with the findings from the adult literature, three types of personality pathology emerged in adolescents: High-functioning/Perfectionistic, Emotionally Dysregulated, and Avoidant/Depressed. The High-functioning prototype showed negative associations with comorbidity and positive associations with treatment response. The Emotionally Dysregulated prototype was specifically associated with externalizing Axis I and Cluster B Axis II disorders, poor school functioning, and adverse events in childhood. The Avoidant/Depressed prototype showed specific associations with internalizing Axis I and Clusters A Axis II disorders, poor peer relationships, poor maternal relationships, and internalizing disorders in first-degree relatives. CONCLUSIONS: These data support the presence of at least three diagnostically meaningful personality prototypes in adolescents with EDs, similar to those found previously in adults. Diagnosis of adolescents with EDs may be usefully supplemented by the assessment of personality style.

Questioning the coherence of histrionic personality disorder: borderline and hysterical personality subtypes in adults and adolescents.

After the introduction of histrionic personality disorder (HPD), nosologists struggled to reduce its overlap with borderline personality disorder and other PDs. We studied the coherence of HPD in adults and adolescents as part of 2 larger studies. Clinicians described a random patient with personality pathology using rigorous psychometrics, including the SWAP-II (a Q-sort that captures personality and its pathology in adults) in study 1 and the SWAP-II-A (the adolescent version) in study 2. Using DSM-IV-based measures, we identified patients who met HPD criteria with varying degrees of diagnostic confidence. Central tendencies in the SWAP-II and SWAP-II-A profiles revealed that both the most descriptive and most distinctive features of the patients included some features of HPD but also many features of borderline personality disorder. Q-factor analyses of the SWAP data yielded 3 types of patients in each of the 2 samples. The HPD diagnosis may not be sufficiently coherent or valid.

Clinical utility of five dimensional systems for personality diagnosis: a "consumer preference" study.

This study compares the clinical relevance and utility of five dimensional diagnostic systems for personality disorders that have been proposed for the forthcoming edition of DSM (DSM-V): (1) a criteria counting model based on current DSM-IV diagnostic criteria; (2) a prototype matching model based on current DSM-IV diagnostic criteria; (3) a prototype matching model based on the Shedler-Westen Assessment Procedure (SWAP); (4) the Five Factor Model; and (5) Cloninger's Psychobiological Model. A random national sample of psychiatrists and psychologists applied all 5 diagnostic systems to a patient in their care and rated the clinical utility of each system. The SWAP Prototype Matching and DSM-IV Prototype Matching models were judged most clinically useful and relevant. The Five Factor Model and Cloninger's Psychobiological Model were judged least useful. The prototype matching systems most faithfully capture the personality syndromes seen in clinical practice, and permit rich descriptions of diagnostic constructs without a proportionate increase in user effort. A prototype matching approach to personality diagnosis deserves consideration for DSM-V.