Factor structure of self-reported clinical disorders and personality disorders: a review of the existing literature and a factor analytical study.

OBJECTIVES: The aim of this research is to add to the current understanding of the latent factor structure of personality disorders by performing a review of the existing literature (Study 1) and a factor analytical study on the factor structure and the relationship between self-reported Axis I and Axis II psychopathology (Study 2). DESIGN: The current research (Study 2) is cross-sectional and multicenter. RESULTS: We found support for the assumption that the borderline personality disorder is a multidimensional construct. Second, we found evidence for a single-factor structure of the narcissistic, dependent as well as the avoidant personality disorder. Third, we found support for the current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) distinction between Axis I and Axis II, Axis I psychopathology being explained by the factor neuroticism and Axis II disorders to be further subdivided into the higher order factors of internalizing and externalizing pathology. CONCLUSIONS: An adaptation to the current DSM-IV borderline personality criteria should be made, while various findings show that the borderline construct is multidimensional. Second, deletion of the dependent and narcissistic personality in the DSM-V might be unjust. Third, Axis I psychopathology can be explained by the factor neuroticism, and Axis II disorders should be further subdivided into the higher order factors of internalizing and externalizing pathology.

El sacrificio de la validez a expensas de la habilidad en psicopatología: mirando por un cristal opaco / Sacrificing validity for feasibility in psychopathology: seeing through a dark glass

La mejora en el acuerdo interexaminadores y test-retest en el diagnóstico psiquiátrico puede ser considerada como uno de los grandes logros de la Psiquiatría en el último cuarto de siglo. No obstante, la homogeneización y operativización de criterios puede presentar algunos inconvenientes: el incremento de la comorbilidad entre trastornos y la validez probablemente deficitaria de algunas entidades nosológicas podrían señalarse como los más destacables. El empleo de sistemas diagnósticos operativos no ha redundado en una mayor profundización en el análisis psicopatológico, dejando de lado una rica y compleja información, necesaria para profundizar en la etiopatogenia de los trastornos, correlacionar la clínica con las alteraciones biológicas subyacentes y tomar decisiones pronosticas y terapéuticas. Analizamos las repercusiones que este hecho tiene en la validez de diversas categorías diagnósticas, pasando por la "depresión mayor" (cuya validez podría ser menor que la de la melancolía clásica), los trastornos de ansiedad, distimias y somatomorfos (de menor estabilidad y validez que el "neuroticismo" como dimensión internalizadora ante el estrés y el denominado "síndrome neurótico general") y los trastornos de personalidad (que presentan una escasa estabilidad diagnóstica y gran variabilidad de prevalencia en distintos estudios, excepción hecha del trastorno antisocial).

The improvement in interater and test-retest reliability could be considered as one of the better conquests for the last-quarter-of-XXth-century Psychiatry. However, this homogeneity and operativizing of diagnostic criteria has added some disadvantages to diagnostic procedure: high ratios of comorbidity and loss of categorial validity could be considered as undesirable consequences of this event. The use of operative diagnostic systems but not the go-deeply-into psychopathological analysis has removed an important and rich information. This loss of information could compromise the study of ethiopatogenia; correlations between symptoms and neurobiological alterations; and prognosis and therapeutic decisions. We analyze the consequences of this event in the validity of diagnosis, from "major depression" (that may be considered as a less valid category than classical melancholia) to anxiety disorders, dysthymia and somatoform disorders (lossing stability and validity in relation to "neurotic general syndrome" or "neuroticism" as an internalizing condition), and also personality disorders (characterized by longitudinal diagnostic unstability and differents ratios of prevalence, excluding antisocial personality disorder).

How an age of anxiety became an age of depression.

CONTEXT: During the 1950s and 1960s, anxiety was the emblematic mental health problem in the United States, and depression was considered to be a rare condition. One of the most puzzling phenomena regarding mental health treatment, research, and policy is why depression has become the central component of the stress tradition since then. METHODS: This article reviews statistical trends in diagnosis, treatment, drug prescriptions, and textual readings of diagnostic criteria and secondary literature. FINDINGS: The association of anxiety with diffuse and amorphous conceptions of "stress" and "neuroses" became incompatible with professional norms demanding diagnostic specificity. At the same time, the contrasting nosologies of anxiety and depression in the Diagnostic and Statistical Manual of Mental Disorders III (DSM-III) extended major depressive disorder to encompass far more patients than any particular anxiety disorder. In addition, antidepressant drugs were not associated with the stigma and alleged side effects of the anxiolytic drugs. CONCLUSION: Various factors combined between the 1970s and the 1990s to transform conditions that had been viewed as "anxiety" into "depression." New interests in the twenty-first century, however, might lead to the reemergence of anxiety as the signature mental health problem of American society.

[Peculiarities of therapy of neurotic disorders in patients with rheumatoid arthritis].

Evaluation of neurotic disorders (ND) in 168 patients with rheumatoid arthritis revealed them in 65.6% of the cases including 22.6% weak, 31.7% moderate and 14.9% severe ones. Asthenovegetative disorders were most frequently detected (61.3%). They associated with emotional, hypochondriac, hysterical, and obsessional disorders in 24.4, 14.3, 9.5, and 4.8% of the patients respectively. ND were treated depending on their type and severity. Mild ND were managed by combined therapy including general tonics, physiotherapeutic procedures, and remedial gymnastics. Patients with moderate ND were given sedative medicines (novopassit, sedavit, glycine, peony tincture). Severe ND were managed using antidepressants and tranquilizers. Duration of therapy was 10-21 days depending on its form. The treatment eliminated all symptoms of ND in 66 (54.1%) and reduced them in 44 (36.1%) of the patients. The outcome of psychotherapy was regarded as unsatisfactory in 11.5%, satisfactory in 26.2%, and positive in 62.3% of the patients. These values in a control group of 46 patients without HD were 10.8, 37.0, and 52.2% respectively.

Affective lability: separable from neuroticism and the other big four?

The goals of the current study were to use specific measures of affective lability and neuroticism to examine the nomological network surrounding both constructs and to test the degree to which a measure of general personality can account for variability in affective lability. Using a psychiatric outpatient sample (n=48), we assessed personality disorder (PD) symptoms, personality, and level of functioning across a range of domains. Neuroticism and affective lability demonstrated a small but significant positive correlation and manifested a divergent pattern of correlations with PDs and measures of functioning. Specifically, neuroticism was correlated primarily with Borderline, Avoidant and Dependent PDs, whereas affective lability was primarily correlated with Cluster B PDs. In addition, neuroticism evinced significant correlations with a range of functional impairments, whereas affective lability was correlated only with self-harm. Regression analyses demonstrated that a substantial portion of the variance in affective lability scales can be explained by Five-Factor Model domains, particularly if the narrower facets are used. The current findings suggest that neuroticism and affective lability are related but in a complex manner that involves other basic personality domains in addition to neuroticism.

Effectiveness of day hospital treatment for anorexia nervosa and bulimia nervosa.

The aim of this observational study was to examine the short-term effectiveness of a structured, largely manualised day hospital treatment, as well as the stability of short-term effects in patients with anorexia nervosa (AN) and bulimia nervosa (BN). Eighty-three patients, 47 with AN and 36 with BN, were assessed at pre-treatment, at the end of the day hospital treatment and at follow-up approximately one year after post-treatment. Outcome measures were body mass index (BMI), disturbed eating attitudes and behaviours assessed by the Eating Disorder Inventory (EDI), frequency of bingeing and purging, and general psychopathology assessed by the Symptom Checklist-90 (SCL-90). At the end of the day hospital treatment, significant improvements could be found on all outcome variables (frequency of binge eating/vomiting/laxative abuse, BMI and core EDI-subscales 'drive for thinness'/'bulimia'/'body dissatisfaction'). Effect sizes were generally large (.74 > d < 2.44). The effects were maintained or improved until follow-up (18 months). At follow-up, 40.2% of AN patients and 40.4% of BN patients could be classified as remitted. General psychopathological impairment was also significantly reduced at post-treatment and maintained until follow-up. The results demonstrate both the short-term effectiveness and long-term stability of day hospital treatment in a large sample of patients with anorexia and BN.

[Validity of axis III "Conflicts" of Operationalized Psychodynamic Diagnostics (OPD-1)--empirical results and conclusions for OPD-2]. / Validität der Konfliktachse der Operationalisierten Psychodynamischen Diagnostik (OPD-1) - empirische Ergebnisse und Folgerungen für die OPD-2.

OBJECTIVE: Using specific psychometric instruments, we investigate criteria-related validity of axis III ("conflicts") of OPD-1 by a priori formulated hypotheses concerning the relations to the main conflict/mode. METHODS/SAMPLE: A consecutive sample of 105 psychotherapy inpatients was examined using self-assessment scales (Inventory of Interpersonal Problems; Rosenberg Self-Esteem Scale, Test of Self-Conscious Affect; Toronto Alexithymia-Scale; Frankfurt Self Concept Scales) and videotaped OPD research interviews in the first week after admission to the hospital. Two OPD-certified raters first rated the interviews independently, then in a consensus rating. RESULTS: Due to the different frequency of the main conflict and mode, evaluation of 4 of 7 conflicts was possible. The a priori hypotheses could be confirmed for the conflicts Dependence versus Autonomy (both modes), Submission versus Control (active mode), Desire for Care versus Autarchy (active mode), and Self-Value (passive mode). DISCUSSION: Confirmation of the a priori hypotheses indicates validity of axis III (Conflicts) of OPD. We discuss the small numbers of some conflicts, the comparison of expert rating OPD with self-assessment and the meaning of the results for OPD-2.

The cognitive behavioural model of medically unexplained symptoms: a theoretical and empirical review.

The article is a narrative review of the theoretical standing and empirical evidence for the cognitive behavioural model of medically unexplained symptoms (MUS) in general and for chronic fatigue syndrome (CFS) and irritable bowel syndrome (IBS) in particular. A literature search of Medline and Psychinfo from 1966 to the present day was conducted using MUS and related terms as search terms. All relevant articles were reviewed. The search was then limited in stages, by cognitive behavioural therapy (CBT), condition, treatment and type of trial. Evidence was found for genetic, neurological, psychophysiological, immunological, personality, attentional, attributional, affective, behavioural, social and inter-personal factors in the onset and maintenance of MUS. The evidence for the contribution of individual factors, and their autopoietic interaction in MUS (as hypothesised by the cognitive behavioural model) is examined. The evidence from the treatment trials of cognitive behavioural therapy for MUS, CFS and IBS is reviewed as an experimental test of the cognitive behavioural models. We conclude that a broadly conceptualized cognitive behavioural model of MUS suggests a novel and plausible mechanism of symptom generation and has heuristic value. We offer suggestions for further research.

Rorschach test findings at the beginning of treatment and 2 years later, with a 30-year follow-up.

In this article, I report a case containing 2 Rorschach assessments-the first (R1) 30 years ago at the beginning of a 4-year period of psychotherapy and the second (R2) 2 years later. I also recently contacted the patient to obtain information about his life during the 26 years since termination. This report examines the 2 Rorschach protocols-combining the Comprehensive System (CS; Exner, 2003) structural summaries with thematic content analysis-in relation to the patient's history, treatment, and 30-year outcome. I focus on the change between R1 and R2, particularly the shift from an introversive to an ambitent EB and a corresponding shift from 6 Y responses on R1 to 6 m responses on R2. In the clinical interpretation, I considered these shifts in a context of the patient's patterns of managing destabilization and overstimulation.

Cultures of categories: Psychological diagnoses as institutional and political projects before and after the transition from state socialism in 1989 in East Germany.

How can psychological categories be understood as historical, political, and cultural artifacts? How are such categories maintained by individuals, organizations, and governments? How do macrosocietal changes-such as the transition from state socialism in East Germany in 1989-correlate with changes in the social and organizational structures that maintain psychological categories? This essay focuses on how--pre-1989--the category of neurosis (as a mental disorder) became entwined with East Germany's grand socialist project of creating new socialist personalities, a new society, and a new science and on how diagnostic preferences were adapted, modified, and extended by local cultural and institutional practices. It also examines how post-1989 the category of neurosis became redefined in accord with a formerly West German psychotherapeutic paradigm and was eventually obliterated by the bureaucratic health care system of the new Germany. East German practitioners adopted new therapeutic guidelines and a new language to make sense of the "normal", "neurotic", and "pathological" self in terms of "individualizing forms of knowledge" that tied in with efforts to remake East German citizens as liberal democratic subjects. At the same time, practitioners' clinical practice remained based upon face-to-face encounters in which formal guidelines and stipulations were often superseded by local, interactional, institutional, and cultural practices and contingencies.

[KON-2006--Neurotic Personality Questionnaire]. / KON-2006 Kwestionariusz osobowosci nerwicowej.

AIM: Construction of a questionnaire describing personality traits connected to the occurrence and persistence of neurotic disorders. METHOD: Responses of 794 patients (before treatment) and 520 persons from the control group on items of the constructed personality questionnaire and the symptom checklist "0". Analyses of subscales reliability and item-scale correlations, test-retest and split-half reliability. Factor analyses estimating internal reliability of the questionnaire. Cross-validation with the KO"0". symptom checklist RESULTS: Psychometric properties of KON-2006 questionnaire indicate that it is consistent and reliable enough. Validity analyses indicate a large probability that the X-KON coefficient informs on personality dysfunctions related to neurotic disorders. CONCLUSIONS: The Neurotic Personality Questionnaire KON-2006 may serve to estimate personality traits connected to the occurrence and persistence of neurotic disorders as well as changes resulting from psychotherapy.

Dimensional models of personality disorder: coverage and cutoffs.

Two major challenges that must be addressed by dimensional models, if they are to be considered viable alternatives to the present categorical system for diagnosing personality disorders, involve the issues of coverage and cutoffs. Several dimensional models of personality and personality pathology are evaluated with these issues in mind. There is growing consensus for the relevance of at least four higher-order domains of personality functioning that are clearly related to personality pathology: neuroticism/negative affectivity/emotional dysregulation, extraversion/positive emotionality, dissocial/antagonistic behavior, and constraint/compulsivity/conscientiousness. A proposal for developing a dimensionally based diagnostic system for personality disorders incorporating these higher-order traits is offered.

DSM criteria for major depression: evaluating symptom patterns using latent-trait item response models.

BACKGROUND: Expert committees of clinicians have chosen diagnostic criteria for psychiatric disorders with little guidance from measurement theory or modern psychometric methods. The DSM-III-R criteria for major depression (MD) are examined to determine the degree to which latent trait item response models can extract additional useful information. METHOD: The dimensionality and measurement properties of the 9 DSM-III-R criteria plus duration are evaluated using dichotomous factor analysis and the Rasch and 2 parameter logistic item response models. Quantitative liability scales are compared with a binary DSM-III-R diagnostic algorithm variable to determine the ramifications of using each approach. RESULTS: Factor and item response model results indicated the 10 MD criteria defined a reasonably coherent unidimensional scale of liability. However, person risk measurement was not optimal. Criteria thresholds were unevenly spaced leaving scale regions poorly measured. Criteria varied in discriminating levels of risk. Compared to a binary MD diagnosis, item response model (IRM) liability scales performed far better in (i) elucidating the relationship between MD symptoms and liability, (ii) predicting the personality trait of neuroticism and future depressive episodes and (iii) more precisely estimating heritability parameters. CONCLUSIONS: Criteria for MD largely defined a single dimension of disease liability although the quality of person risk measurement was less clear. The quantitative item response scales were statistically superior in predicting relevant outcomes and estimating twin model parameters. Item response models that treat symptoms as ordered indicators of risk rather than as counts towards a diagnostic threshold more fully exploit the information available in symptom endorsement data patterns.

Lista integrada para el diagnóstico de los trastornos neuróticos, secundarios a situaciones estresantes y somatomorfos (LID-TNES) / Integrated list for the diagnostic of neurotic disorders, secondary dysfuntions to stress and somatomorf disorders (LID-TNES)

Hemos confeccionado un instrumento que contiene los criterios diagnósticos de las dos grandes nosografías actuales (CIE-10 y DSM-IV-TR), que es de fácil uso, útil para el uso clínico y para la investigación, que nos permite realizar el diagnóstico del abigarrado conjunto de los trastornos neuróticos, reacciones a estrés y somatomorfos sin necesidad de utilizar cada una de ellas. Este instrumento consta de 47 ítems que están ordenados siguiendo el orden lógico de la exploración psicopatológica de las diversas funciones psíquicas tal como se realiza en la práctica clínica (AU)

Aportaciones del movimiento estructuralista a la psiquiatría actual (parte II) / Contributions of the structuralism movement to modern

En esta segunda parte nuestra pretensión ha sido presentar las "estructuras clínicas" que se han definido a partir de los presupuestos estructuralistas y estudiar sus características. Más allá de eso, se intentaron establecer correlaciones entre las categorías nosológicas que se muestran en la CIE-10 y las tres estructuras clínicas que se definieron. En ese camino, tropezamos con importantes problemas de los que se ocupó la psiquiatría clásica, (la dicotomía "normalidad/patología", el concepto de la "libertad" como definidor de la patología mental, la "psicotización...... ) a los que dan respuesta los presupuestos teóricos de los que partimos. Finalmente, como conclusión, tratamos de sopesar las aportaciones positivas que el estructuralismo puede hacer al pensamiento psiquiátrico contemporáneo (AU)

Connecting neurosis and psychosis: the direct influence of emotion on delusions and hallucinations.

Diagnostic classification systems contain a core divide between neurosis and psychosis, leading to their separate study and treatment. The basis for the separation of the disorders is outlined and reassessed. It is argued that the empirical evidence does not support such a sharp distinction between neurosis and psychosis. The frequent occurrence of emotional disorder prior to and accompanying psychosis indicates that neurosis contributes to the development of the positive symptoms of psychosis. Psychological theories and experimental evidence concerning the influence of emotion on the content and form of delusions and hallucinations are therefore reviewed. It is argued that in many cases delusions are a direct representation of emotional concerns, and that emotion contributes to delusion formation and maintenance. The content of hallucinations less often directly expresses the emotional concerns of the individual, but emotion can trigger and contribute to the maintenance of hallucinatory phenomena, although how this occurs is not well understood. It is concluded that study needs to be made of the interaction between psychotic and neurotic processes in the development of delusions and hallucinations, and that neurotic and psychotic disorders may have common maintenance processes.