[The advantage of a modern operational approach to the diagnosis of mental disorders. The case of the Bavarian King Ludwig II--an example from biographical research]. / Die Vorzüge einer modernen operationalen Diagnostik psychischer Störungen. Der Fall des Bayernkönigs Ludwig II--ein Beispiel aus der biographischen Forschung.

Worldwide discrepancies in the classification, terminology and diagnosis of mental disorders have induced efforts for unification after World War II. This led to the introduction of an operational diagnostic approach according to strict criteria, at the same time taking into account the comorbidity of disorders. However, this approach is still not routinely used. The consequences of this deficiency are demonstrated here by an example from biographical research referring to the Bavarian King Ludwig II. The study is based on an extensive search of the relevant literature. Although the pathography of this Bavarian king is well documented, the diagnoses published between 1910 and 2010 by altogether 21 specialists, are distributed rather chaotically over 24 diagnostic categories of the ICD-10. Merely in the (probably wrong) diagnosis of a schizophrenic psychosis is there agreement among half of the authors. This is concordant with the expert diagnosis of paranoia by von Gudden and his colleagues (1886) when considering the then contemporary concept of the disorder. According to modern diagnostic principles almost half of the 24 diagnoses can be confirmed. The others have to be regarded as false diagnoses. The conclusion is that modern principles of the diagnosis of mental disorders should be applied according to internationally accepted diagnostic manuals. This approach should be used in, but is not exclusive to, biographical research. Precondition is, of course, the exact knowledge and careful application of these principles.

[The Six Factor Test--a personality questionnaire for clinical practice and research]. / Der Sechs-Faktoren-Test zur Erfassung der Persönlichkeit in der klinischen Praxis und Forschung.

BACKGROUND: The Six factor Test (SFT) is a personality questionnaire for assessment of the "big five" (neuroticism, extraversion, conscience, aggressivity, openness to experiences) and piety in patients with mental disorders and healthy subjects. METHODS: In a study of 360 probands (125 depressive and bipolar patients, 150 first-degree relatives of these patients, and 85 controls), the reliability and validity of the SFT was examined. Thirty-five controls and 79 relatives were reinvestigated after around 6.5 years. RESULTS: The factorial structure could be replicated, and the concurrent validity was moderate to high. Acceptable internal consistency was observed, with the exceptions of "openness" and "agreeableness". The retest reliability was high, with the exception of "openness". Patients differed from controls in neuroticism and "openness". These factors were also predictive for the first onset of psychiatric disorders in controls and relatives, respectively. CONCLUSION: The SFT is a short und simple instrument for the assessment of personality in clinical samples and controls. Reliability and validity of the three main scales (neuroticism, extraversion, and conscience) were acceptable. The corresponding coefficients of the three shorter scales, in particular of openness, were partly much lower.

Variants of premorbid personality and personality disorder: a taxonomic model of their relationships.

From a biographical analysis of approximately 500 case records of patients with various kinds of mental state (in particular mood, anxiety and schizophrenic) disorders, a typology of premorbid personality variants was derived. It comprises three "affective types" dominating in patients with major affective disorders and three "neurotoid types" prevailing in other, above all anxiety and schizophrenic, disorders. These types were operationalized so that they could be assessed by means of a diagnostically "blind" rating of biographical case reports or of interview protocols concerning the premorbid development of clinically remitted patients. The material for the present analysis consisted of ratings regarding 120 subjects (100 patients and 20 healthy controls) who had been interviewed within a project primarily aiming at the development of a novel assessment tool, the Biographical Personality Interview (BPI). This data was used for constructing a comprehensive taxonomic model of premorbid personality variants and their relationships to personality disorders. The intercorrelation of type-scores representing the six premorbid personality types suggests a circular order of these types, opposing the "neurotoid types" on one side to the "affective types" on the other side of the circle (circumplex) along a dimension of mental abnormality vs. normality. Two types, the ("neurotoid") nervous, tense type, and the ("affective") manic type are contrasted with the ("affective") melancholic and the ("neurotoid") anxious, insecure types along an orthogonal dimension of rather changeable vs. rather constant habitual behaviour. This order is confirmed by the correlation of type-scores with factor scores of the two main dimensions of BPI-item scores. It is also concordant with the correlation of type-scores and scores on questionnaire scales of personality. Personality disorders as maladapted extreme variants of personality can be located outside the circle according to their similarity or dissimilarity with the six premorbid personality types. They are necessarily distributed almost exclusively along the "neurotoid" side of the circumplex. This two-dimensional model of variants of premorbid personality and personality disorders is in basic agreement with models derived from dimensions of personality in mentally healthy subjects and with findings concerning the comorbidity among personality disorders. Further empirical studies are required for choosing or developing the most appropriate model of the relationships between personality variants and personality disorders.

The Biographical Personality Interview (BPI)--a new approach to the assessment of premorbid personality in psychiatric research. Part I: Development of the instrument.

The Biographical Personality Interview (BPI) is a research instrument for the retrospective assessment of premorbid personality traits of psychiatric patients. Its construction is based on results of a series of investigations in which biographical data from psychiatric case notes were analysed with respect to premorbid personality traits. In order to avoid methodological shortcomings of the utilisation of clinical records, an interview technique was developed. It is applied by two independent, specially trained investigators who are kept "blind" regarding any clinical data of the subject under study. One of them has to conduct the interview of a clinically remitted patient and to provide an interview protocol, the other one has to rate personality traits from that protocol along a large series of purely descriptive items. Sum scores for six personality structures ("types") are calculated and the case is then assigned to the intra-individually dominating personality type according to the highest of these scores.

The Biographical Personality Interview (BPI)--a new approach to the assessment of premorbid personality in psychiatric research. Part II: Psychometric properties.

The Biographical Personality Interview (BPI) was applied to 179 subjects (158 psychiatric patients and 21 probands from the general population); 100 patients and 20 healthy controls served as a validation sample; the others had been interviewed during the training period or did not meet the inclusion criteria for the validation of the BPI. The acceptance of the interview was high, the inter-rater reliability of the ratings of premorbid personality structures ("types") varied between 0.81 and 0.88 per type. Concurrent validity of the typological constructs as assessed by means of the BPI was inferred from the intercorrelations of type scores and correlations of these scores with questionnaire data and proved to be adequate. Clinical validity of the assessment was indicated by statistically significant differences between diagnostic groups. Problems and further developments of the instrument and its application are discussed.

Personality in patients with affective disorders and their relatives.

BACKGROUND: In studies of both patients and high-risk subjects, particular patterns of personality have been found to be associated with affective disorders. Neuroticism and features of the melancholic type of personality seem to be risk factors for depression while premorbid features of the manic type of personality predominate in patients with more manic than depressive episodes. While neuroticism prevails in the majority of mental disorders, the 'affective' personality variants appear to be more specifically associated with affective disorders. METHODS: Personality features were investigated in 122 recovered patients with affective disorders, 58 first-degree relatives (high-risk subjects (HR)) and in the respective control groups (n=48; n=29). Patients were subdivided into: unipolar depression (melancholic subtype); bipolar II; bipolar I with more depressive episodes and bipolar I with more manic episodes. Personality measures were based on the Biographical Personality Interview (BPI) and the Munich Personality Test (MPT). RESULTS: The melancholic personality type (BPI) decreased from the unipolar depressives to the mainly manic group, while features of the manic type increased. MPT scores failed to discriminate between subgroups of patients. HR were significantly more introverted and had a stronger orientation towards social norms than controls according to the MPT, and showed a tendency towards the melancholic type according to the BPI. LIMITATIONS: The sizes of some groups or subgroups are relatively small. Therefore, they have to be enlarged in the continuation of the study so as to increase the power of the statistical tests and thus to ascertain the robustness of the results. CONCLUSION: Features of the typus melancholicus seem to be a risk factor for depression. The identification of highly predictive risk factors provides an opportunity for the development of prevention programs.

The pre-morbid psychometric profile is stable over time in subjects at high familial risk for affective disorders.

BACKGROUND: The pre-morbid personality profile 'autonomic lability' (e.g. elevated neuroticism, frequent somatic complaints and increased interpersonal sensitivity) is suggested to be an antecedent of major depression. Recently, we reported that the psychometric profile of healthy first-degree relatives of patients with an affective disorder (so-called high-risk probands; HRPs) was characterized by the personality trait 'rigidity' in association with 'autonomic lability' and speculated that such a profile might be a potential candidate for a true vulnerability marker for affective disorders. Because one major prerequisite for any valid vulnerability marker is its stability over time, we re-examined our HRPs about four years after index assessment. METHODS: Sixteen HRPs from the initial sample (n=54) participated in the follow-up investigation which, on average, took place 47 months after index assessment. All these HRPs had remained mentally healthy during the follow-up period. RESULTS: The psychometric profile was remarkably stable over the four-year period when considering the total group of the 16 HRPs. On an individual level, similar findings were obtained. Allowing a fluctuation within a narrowly defined 'band width', a constancy of the self-ratings was found in 75% of the HRPs, within a broader 'band width' this was the case in 88% of the HRPs. LIMITATIONS: The power of the present observations appears to be somewhat limited due to the still small sample size of HRPs re-investigated and the fact that the control probands were not yet re-examined. CONCLUSIONS: The present follow-up findings in 16 probands at high risk for an affective disorder indicate a sufficient stability of the psychometric profile over time, so that this requirement for a true vulnerability marker is fulfilled.

Personality traits of Japanese patients in remission from an episode of primary unipolar depression.

Personality traits were assessed by means of the Munich Personality Test (MPT) in 75 Japanese subjects, 27 patients in remission from an episode of moderate to severe primary unipolar depression, with melancholic features during one episode or more of the disorder, in 24 patients in remission from other non-organic mental disorders and in 24 healthy controls. Compared with healthy controls, unipolar depressives displayed decreased Frustration Tolerance and elevated Rigidity as well as a stronger Orientation towards Social Norms. No significant difference was found between patients in remission from either unipolar depression or other mental disorders. However, the increase in Rigidity in comparison with healthy subjects was significant in the depressives only whereas the other patients, in contrast to the depressives, had significantly lower scores in Extraversion than the healthy subjects. Our results in Japanese patients are similar to findings of previous German studies, including two high risk studies, in which the same assessment instrument was used. This suggests that, beyond cultural differences, Rigidity, possibly in combination with a strong Orientation towards Social Norms and a reduced Frustration Tolerance, is a stable vulnerability marker for at least the more severe forms of primary unipolar depression.

Personality differences between patients with major depression and bipolar disorder--the impact of minor symptoms on self-ratings of personality.

The study explores whether minor symptoms of patients in recovery from a mood disorder have an impact on self-ratings of personality with special consideration of potential differences between diagnostic groups. 90 recovered DSM-III-R major unipolar depressives and 167 recovered bipolars were compared with respect to scale values of the Munich Personality Test (MPT). Major depressives showed significantly higher scores on the MPT scales Rigidity and Orientation towards Social Norms, and lower scores on Extraversion than the bipolar patients. Using a LISREL-model, psychopathology was found to have a significant impact on Neuroticism and Extraversion, but not on Rigidity and on Orientation towards Social Norms. Controlling for symptomatology, the differences in the MPT scale values of the two diagnostic groups remained significant and can hardly be sufficiently explained by residual symptomatology.

Premorbid personality in patients with uni- and bipolar affective disorders and controls: assessment by the Biographical Personality Interview (BPI).

The relationship between premorbid personality and subtypes of affective disorder was investigated by means of the Biographical Personality Interview (BPI) and by a self-rating scale. Interviewer and rater (BPI) were blind to diagnosis. A total of 52 patients with unipolar depression or bipolar II disorder (D/Dm), 32 bipolar-I patients (DM) and 39 control subjects (C) were examined. Expert rating of "typus melancholicus" features (BPI) were found to be more pronounced in D/Dm than in DM and C. "Typus manicus" features were also distinguished between both clinical groups, whereas anxious-insecure features were not significantly different between the groups of patients. In contrast to the expert-rated personality variants, self-rating of personality features did not reveal any significant differences between the two clinical groups. Potential sources of the discrepancies between the questionnaire data and the interview data are discussed. It is concluded that premorbid features of "typus manicus" and "typus melancholicus" predicted, respectively, a predominant manic and a predominant depressive course of an affective disorder.

[Research into premorbid personality in psychiatry in German-speaking countries: the last 3 decades]. / Forschungen zur prämorbiden Persönlichkeit in der Psychiatrie der deutschsprachigen Länder: Die letzten drei Jahrzehnte.

The empirical research in premorbid personality of psychiatric patients has markedly advanced in German speaking countries since adequate research methods were introduced in the middle of the sixties. Among the various results are the following: Kretschmer's typological conception of human constitution were largely refuted and replaced by other conceptions on a methodologically more solid ground; Tellenbach's concept of the "melancholic type" as the premorbid structure of the majority of patients suffering from a unipolar affective disorder with melancholic features could be convincingly validated; this concept was supplemented by that of the "manic type" of personality as the premorbid correlate of the amount of a predisposition to manic episodes within the course of an affective disorder; the premorbid deviations of personality in schizophrenics and neurotics were shown to possess little nosological specificity; furthermore, similar deviations could be demonstrated in the personality of (still healthy) relatives of patients with severe mental disorders; the complex relationships of (premorbid) personality, personality disorders and mental disorders were partly clarified.

Self-rating procedures in the evaluation of antidepressants.

Self-ratings are very practical and economical procedures to measure the severity of depression in intraindividual comparisons. They are sensitive to change induced by therapy and provide findings concerning the global result of therapy and its time course, which are similar to data based on ratings by psychiatrists. Due to their practicability, self-rating procedures contribute to an exact description of the time course of depression in multiple measurement designs. However, the limitations of the validity of self-rating procedures should not be neglected.

The relationship of premorbid personality to subtypes of an affective illness. A replication study by means of an operationalized procedure for the diagnosis of personality structures.

The hypothesis of a relationship between types of premorbid personality and subtypes of an affective illness was tested on the basis of a diagnostically 'blind' assignment of biographical case history data on patients' premorbid development to patterns of personality traits. Data sets of 261 cases with various psychiatric disorders were examined. The rater (R.T.) had to score each item in a list of traits relevant for the diagnosis of the types that had been conceived by D.v.Z. and J.P. The assignment of the ratings to the type concepts was then performed by means of a computer programme. The results regarding the distribution of types over the clinical diagnoses yielded a statistically significant association of the 'affective types' of premorbid personality ('melancholic type' and 'manic type') with affective disorders and the 'neurotoid types' ('anxious insecure type' and 'nervous tense type') with non-affective disorders. Previous findings on the basis of a global rating of types in a smaller sample (n = 42) regarding personality types and subtypes of an affective illness could be replicated by means of the new, operationalized procedure in an enlarged sample (n = 80): On the one hand, a marked preponderance of the 'manic type' of personality was found in bipolar I patients, particularly pronounced in those with a predominantly manic course of the disorder; on the other hand, the 'melancholic type' of personality prevailed in bipolar II and unipolar depressive patients.

Evaluating the new ICD-10 categories of depressive episode and recurrent depressive disorder.

The new ICD-10 categories of 'depressive episode' (F32) and 'recurrent depressive disorder' (F33) were evaluated on the levels of diagnoses, subtypes, syndromes and symptoms. Interrater reliability was analyzed from findings of four independent diagnosticians who rated 100 written psychiatric case records with the help of criteria-related checklists. Agreement was sufficient if patients with and without the diagnosis of a depressive disorder were included (kappa = 0.82), but low in the depressed subsample (kappa = 0.40). Unclear boundaries became apparent for the classification of depressive syndromes as moderate or severe. The results suggest that the ICD-10 concept of depressive disorder is very similar to the well-known international concept of 'major depression'.

Testing the comparability of psychiatric diagnoses in ICD-10 and DSM-III-R.

The compatibility of the classification systems ICD-10 and DSM-III-R was investigated in a sample of 100 psychiatric inpatients with severe affective and psychotic disorders. Four independent raters assessed diagnoses by means of checklists from psychopathological descriptions of case records. Congruence between ICD-10 and DSM-III-R was good for depressive disorders with agreement rates above 80% and fair for bipolar disorders with rates above 60%. Less consistent findings were obtained for schizophrenia with rates of 57.5% for ICD-10 diagnoses and 82.6% for DSM-III-R diagnoses. Agreement for schizoaffective disorder was below 40% and thus insufficient. The results indicate that even small differences in the definitions of mental disorders may result in considerable inconsistencies.

[Personality traits and vulnerability markers--problems of assessment]. / Persönlichkeitszüge als Vulnerabilitätsindikatoren--Probleme ihrer Erfassung.

Personality traits play an increasing role in research on the vulnerability to mental disorders. Problems of their assessment are dealt with here with special reference to work of our own in this area. Personality inventories for self-rating or informants' rating are appropriate instruments for retrospective as well as prospective investigations. They should be short and, at the same time, suites for the assessment of the main dimensions of personality, the "Big Five". The Munich Personality Test (MPT) and the Six Factor Test (SFT) serve as examples in this context. They were already successfully applied in clinical and outpatient settings and in "high-risk" studies. In retrospective investigations, a newly developed method for the operationalized diagnosis of personality types from case history data can be used as well. On the basis of this approach, we have recently developed a Biographical Personality Interview (BPI) which, in combination with personality inventories, can be regarded an optimal device for the assessment of premorbid personality in psychiatric patients.

An operationalized procedure for the recognition of premorbid personality types in biographical case notes on psychiatric patients.

A method for the assessment of six premorbid personality types from biographical data in psychiatric case histories is described. Trained raters have to fill in a list comprising 106 items as descriptors of a patient's premorbid behavioural development. The assignment to the types in question (the "manic type" and its rare variant, the "happy-go-lucky type", the "melancholic type", the "anxious insecure type" and its rare variant, the "unrealistic dreamy type", and finally, the "nervous tense type") is computed on the basis of the item scores by forming type scores and comparing their height intraindividually. The subject under study is assigned to the type reaching the comparatively highest value. Two raters independently analyzed 261 records from which all information on mental disorders in family members and the patient himself/herself as well as all biographical data from the first manifestation of a symptom disorder onwards had been erased by technical assistants. In 106 of the records, a global assignment to the types of premorbid personality had already been performed by one of the authors of the typology. The scores for the same type assessed by the two ratings correlated highly with each other (0.77 to 0.80), the concordance of types reached a kappa-value of 0.55 (P < 0.001), and the results of the operationalized typing agreed in the same order with the result of global typing in the subsample of n = 106.(ABSTRACT TRUNCATED AT 250 WORDS)

Prediction of short-term outcome of neurotic-depressive inpatients. Results of an empirical study of 134 inpatients.

A study was carried out involving 134 neurotic-depressive inpatients (according to ICD-9) treated with cognitive behaviour therapy and in a subgroup additionally with antidepressants. Using standardized rating instruments, a large set of potential predictor variables was tested. After cross-validation according to the split-half technique, only very few of these proved to be suitable as predictors for the main outcome criteria. These predictors included certain aspects of social functioning before index admission, intensity of depressive symptoms at admission and the degree of self-evaluated mood disturbances three weeks after admission. Several predictors known from the literature could not be reproduced in this study, demonstrating the well-known instability of most predictor findings. On the other side, the predictor profile of the neurotic-depressive patients was quite similar to that found in endogenous depressives, a result which might--together with other findings, such as the response of neurotic depressives to antidepressants--question the traditional subclassification of functional depressive states into these subgroups.