Relating DSM-5 section III personality traits to section II personality disorder diagnoses.

BACKGROUND: The DSM-5 Personality and Personality Disorders Work Group formulated a hybrid dimensional/categorical model that represented personality disorders as combinations of core impairments in personality functioning with specific configurations of problematic personality traits. Specific clusters of traits were selected to serve as indicators for six DSM categorical diagnoses to be retained in this system - antisocial, avoidant, borderline, narcissistic, obsessive-compulsive and schizotypal personality disorders. The goal of the current study was to describe the empirical relationships between the DSM-5 section III pathological traits and DSM-IV/DSM-5 section II personality disorder diagnoses. METHOD: Data were obtained from a sample of 337 clinicians, each of whom rated one of his or her patients on all aspects of the DSM-IV and DSM-5 proposed alternative model. Regression models were constructed to examine trait-disorder relationships, and the incremental validity of core personality dysfunctions (i.e. criterion A features for each disorder) was examined in combination with the specified trait clusters. RESULTS: Findings suggested that the trait assignments specified by the Work Group tended to be substantially associated with corresponding DSM-IV concepts, and the criterion A features provided additional diagnostic information in all but one instance. CONCLUSIONS: Although the DSM-5 section III alternative model provided a substantially different taxonomic structure for personality disorders, the associations between this new approach and the traditional personality disorder concepts in DSM-5 section II make it possible to render traditional personality disorder concepts using alternative model traits in combination with core impairments in personality functioning.

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.

Personality disorders in DSM-III and DSM-III-R: convergence, coverage, and internal consistency.

Although many sections of DSM-III-R reflect few changes from DSM-III, the diagnostic criteria for the personality disorders involve more substantial revisions. This study examined the impact of DSM-III-R revisions in terms of convergence with DSM-III, the diagnostic coverage of patients with personality disorders, and the internal consistency of the personality disorder criteria sets. The results demonstrated a substantial divergence between DSM-III and DSM-III-R diagnoses, increased coverage accompanied by a large increase in overlap among personality disorders, and internal consistency estimates of DSM-III-R criterion sets comparable to those in DSM-III.

Reliability of categorical and dimensional judgments of personality disorder.

To investigate interrater reliability on categorical and dimensional judgments of personality disorder, five clinicians completed five different judgment tasks for each of 10 case vignettes. The reliability estimates support previously unconfirmed statements that dimensional judgments are substantially more reliable than categorical diagnoses.

Applicability of personality disorder criteria to hospitalized adolescents: evaluation of internal consistency and criterion overlap.

OBJECTIVE: The authors examined the applicability of personality disorder criteria to adolescent inpatients by evaluating internal consistency and criterion overlap. METHOD: Thirty-eight adolescents and 28 adults were assessed with the Personality Disorder Examination. Within-category cohesiveness (internal consistency) of the criteria was evaluated by examining intercriterion correlations as well as coefficient alpha. In addition, between-category criterion overlap was evaluated by examining "intercategory" intercriterion correlations between all pairs of disorders. Separate analyses were conducted for adolescents and adults, and the groups were compared. RESULTS: Internal consistency appeared to be lower in adolescents, as measured by intercriterion correlation and coefficient alpha, with the largest differences being identified for most cluster B disorders. Intercategory analysis indicated that criterion overlap may be greater among adolescents. CONCLUSIONS: Overall, this psychometric analysis suggests that there may be limitations to the DSMs approach to categorizing personality disorders. For both adolescents and adults, modest degrees of within-category cohesiveness (internal consistency) and between-category criterion overlap were observed. Comparatively, personality disorder criteria in adolescents tended to have lower internal consistency and less discriminant validity. The data raise questions about the construct validity of these disorders--or the applicability of these criteria--within this age group.

A symptom analysis of the DSM-III definition of schizophrenia.

With the recent introduction of DSM-III has come a renewed interest in psychiatric classification. The development of specific criteria for diagnosis was designed to objectify heretofore suspect diagnostic procedures. However, this potential objectivity may be offset by shortcomings in the specific symptoms that define the syndrome. The experiment reported examined the DSM-III definition of schizophrenia by analyzing the characteristics of the individual symptoms. Certain problem areas are noted, and recommendations are made as to how the definition might be strengthened.

Glycosaminoglycan polysulfate (Ateroid) in old-age dementias: effects upon depressive symptomatology in geriatric patients.

1. Glycosaminoglycan polysulfate is a mixture of sulfo-muco-polysaccharides with hypolipidemic activity. A number of clinical studies have indicated that it is effective in improving psychopathology in patients with cardiac and/or cerebral disease associated with arteriosclerosis. 2. A multicenter clinical trial was performed to compare the effects of two different dosages of glycosaminoglycan polysulfate upon depressive symptomatology in patients with multi-infarct dementia and primary degenerative dementia. 3. A total of 39 patients were treated in an 18-week clinical trial which followed a single-blind parallel design. 4. Results indicated that patients with both diagnoses improved significantly in depressive symptomatology over the course of treatment, with particular improvement noted in cognitive disturbance. Drug dosage was not a significant determinant of treatment response for either diagnostic group.

Early manifestations of dementing illness: treatment with glycosaminoglycan polysulfate.

1. In a multicenter, placebo-controlled, double-blind clinical trial in 156 elderly patients with psychopathologic symptoms, glycosaminoglycan polysulfate was found to be a therapeutically effective agent in the treatment of the earliest manifestations of a dementing process. 2. Treatment with glycosaminoglycan polysulfate in the daily dosage of 600 LRU, administered on the basis of a divided dosage schedule for 24 weeks, was significantly superior to an inactive placebo on several outcome measures including the SCAG Total and factor scores (i.e., Cognitive Dysfunction, Withdrawal, Agitation/Irritability and Depression), the NOWLIS Total and Fatiguability factor scores, the MMSE, the HAM-D Total and Vegetative Symptoms factor score and the CGI Severity of Illness and Global Improvement. 3. The drug was well tolerated; vital signs and laboratory measures did not show clinically significant changes within the experimental period.

Glycosaminoglycan polysulfate in the treatment of old age dementias.

1. In a multicenter, placebo-controlled, double-blind clinical trial in 155 elderly patients with cognitive decline, glycosaminoglycan polysulfate was found to be a therapeutically effective agent in the treatment of old age dementias. 2. Treatment with glycosaminoglycan polysulfate in the daily dosage of 600 LRU, administered on the basis of a divided dosage schedule for 12 weeks, was significantly superior to an inactive placebo on several outcome measures including the Wechsler Memory Scale-Russell Revision (Easy Paired Associates Learning and Immediate Visual Reproduction), Mini Mental State Examination, the Sandoz Clinical Assessment Geriatric (Cognitive Dysfunction and Depression), Hachinski Dementia Scale, Brief Psychiatric Rating Scale (Confusion and Depressive Withdrawal) and Global Improvement Scale of the Clinical Global Impression. 3. Adverse effects with glycosaminoglycan polysulfate were few and mild. The drug was equally well tolerated and equally effective in the two major dementias of old age, i.e., primary degenerative and multi-infarct. The number of abnormal laboratory test readings remained essentially unchanged from pre-treatment to post-treatment.

Matchmaking in psychotherapy: patient-therapist dimensions and their impact on outcome.

Patient-therapist matching was investigated using recent theoretical and methodological developments to overcome some of the limitations that have hindered similar past efforts. Two hypotheses were tested: (a) Therapeutic outcome is affected by the interaction between patients' and therapists' self-concepts, and (b) increasing anticomplementarity between therapist self-concept and therapists' perceptions of patients' behavior is negatively associated with patient improvement. Data from the first 2 cohorts of the Vanderbilt II Psychotherapy Project were analyzed. They included the therapies of 16 experienced therapists, who saw a total of 48 patients (38 women and 10 men) in time-limited psychotherapy. Patients' ages ranged from 24 to 64 years (M age = 40). Outcome was measured from the perspective of the patient, therapist, and evaluating clinician. Each hypothesis was supported, but not across all 3 outcome perspectives.

Classification of mental disorder as a collection of hypothetical constructs.

In this article, I explore the implications of viewing psychiatric classification as a collection of hypothetical constructs. In this view, a taxonomic construct includes meaning surplus to the descriptive features provided by operational definitions, such as those provided in the American Psychiatric Association's 4th edition of the Diagnostic and Statistical Manual of Mental Disorders. This surplus meaning includes ties to etiology and treatment that for many disorders are as yet unknown. Despite these unknowns, it is proposed that a taxonomic construct must be embedded in a theory that provides some meaningful context for the construct and that falsification of such theories constitutes the primary enterprise of taxonomic research.

Borderline personality: traits and disorder.

Although the 5-factor model (FFM) has been advocated as an alternative to representing the construct of borderline personality, some argue that this diagnosis carries essential information that is not well captured by the FFM. The present study examined antecedent, concurrent, and predictive markers of construct validity in a sample of 362 patients with personality disorders. The results indicated that neuroticism best distinguished borderline and nonborderline patients, whereas the FFM as a whole captured a sizable proportion of the variance in the borderline diagnosis. However, the residual of the borderline diagnosis that was not explained by the FFM was found to be significantly related to childhood abuse history, family history of mood and substance use disorders, concurrent symptoms, and 2-year and 4-year outcomes. Thus, some elements of the borderline diagnosis may not be fully captured in a 5-factor representation.

Negativism in evaluative judgments of words among depressed outpatients with borderline personality disorder.

This study contrasted the frequency of negativistic evaluative judgments to words of various emotional content between two groups of patients with Major Depressive Disorder (MDD) (20 patients with a comorbid diagnosis of Borderline Personality Disorder (BPD) and 20 patients without BPD) and a group of 20 community adult Controls. BPD patients made more "dislike" judgments with neutral words than MDD patients and Controls. The performances of the MDD patients were more similar to the Control group than to the BPD group, despite negligible differences between the two patient groups in the severity of depressive symptoms and overall psychopathology. As a whole, these data indicate that the presence of borderline features in patients with MDD can be an important qualifier in terms of patients attitudinal dispositions.

The Collaborative Longitudinal Personality Disorders Study: reliability of axis I and II diagnoses.

Both the interrater and test-retest-retest reliability of axis I and axis II disorders were assessed using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and the Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV). Fair-good median interrater kappa (.40-.75) were found for all axis II disorders diagnosed five times or more, except antisocial personality disorder (1.0). All of the test-retest kappa for axis II disorders, except for narcissistic personality disorder (1.0) and paranoid personality disorder (.39), were also found to be fair-good. Interrater and test-retest dimensional reliability figures for axis II were generally higher than those for their categorical counterparts; most were in the excellent range (> .75). In terms of axis I, excellent median interrater kappa were found for six of the 10 disorders diagnosed five times or more, whereas fair-good median interrater kappa were found for the other four axis I disorders. In general, test-retest reliability figures for axis I disorders were somewhat lower than the interrater reliability figures. Three test-retest kappa were in the excellent range, six were in the fair-good range, and one (for dysthymia) was in the poor range (.35). Taken together, the results of this study suggest that both axis I and axis II disorders can be diagnosed reliably when using appropriate semistructured interviews. They also suggest that the reliability of axis II disorders is roughly equivalent to that reliability found for most axis I disorders.

The Collaborative Longitudinal Personality Disorders Study: development, aims, design, and sample characteristics.

This paper describes the aims, background, design, and methods used in a collaborative longitudinal study of Axis II personality disorders (PDs). This study examines the putative stability of selected PD diagnoses and criteria, what factors affect their course, and whether their stability and course distinguishes them from a representative Axis I disorder. This article also describes the acquisition and demographics of the sample on whom the study is being done. A prospective, repeated measures investigation of the stability of PDs is now underway at multiple clinical settings in four collaborating urban sites in Boston. New Haven, New York, and Providence. Diagnostic assignments are based on semistructured interview assessments (by clinically trained raters) and confirmed by at least one additional contrasting diagnostic method. The sample consists of 668 treatment seeking and reliably diagnosed adults recruited from a broad range of clinical sites. By design, patients in the sample met standards for one of five diagnostic subgroups: (a) schizotypal (N = 86); (b) borderline (N = 175); (c) avoidant (N = 157); (d) obsessive-compulsive (N = 153) personality disorders or a control group having (e) major depressive disorder without personality disorder (N = 97).

An empirical comparison of interpersonal and DSM-III approaches to classification of personality disorders.

In recent years, a number of authors have attempted to map correspondences between interpersonal models and traditional psychiatric classification. Many of the proposed relationships are plausible from a theoretical standpoint, but at present little empirical evidence has been gathered in support of these speculations. This paper describes the results of a project that suggests that the convergence of these two approaches to personality taxonomy is not as high as might be expected. In particular, it seems that DSM-III personality disorders are not as differentiated with respect to affiliative needs as has been hypothesized.

Passive-aggressive personality disorder: the demise of a syndrome.

This article presents an explanation and critique of the rationale for dropping passive-aggressive personality disorder (PAPD) from DSM-IV. The clinical and research literature on PAPD is reviewed along with the historical changes in definition, diagnostic criteria, and usage. PAPD can be reliably diagnosed, is fairly prevalent, and has good internal consistency. Because PAPD is no less valid than other personality disorders, and describes clinical phenomena that are unique among personality disorders, we recommend the reinstatement of PAPD in the official diagnostic nomenclature.