Avoidant personality disorder and implicit schema-congruent information processing bias: a pilot study with a pragmatic inference task.

Cognitive theory of personality disorders hypothesizes that each personality disorder is characterized by typical maladaptive schemes and that these schemas direct the processing of information resulting in schema-congruent biases. With regard to the avoidant personality disorder, these hypotheses were put to an initial test in a pilot study, using a self-report questionnaire to asses DSM-III-R personality pathology, a belief questionnaire to assess avoidant schemas and a pragmatic inference task to assess schema-congruent implicit attributional bias. Participants were students (n = 57) who scored high or low on DSM-III-R avoidant personality pathology. As predicted from cognitive theory, DSM-III-R avoidant personality pathology was associated with avoidant beliefs (t(45.1) = 4.68, p < 0.001) and avoidant beliefs were associated with schema-congruent information processing bias (t(55) = 2.17, p = 0.02, one-tailed test). However, DSM-III-R avoidant personality pathology was not associated with schema-congruent information processing bias (t(55) = 0.17, p = 0.43, one-tailed test). In addition to avoidant beliefs, low self-esteem was also related to the information processing bias. Social phobia and general personality pathology, two other control variables, were not. The findings warrant further study using the pragmatic inference task in a clinical group.

Assumptions in borderline personality disorder: specificity, stability and relationship with etiological factors.

The specificity and stability of a set of assumptions hypothesized to be characteristic of Borderline Personality Disorder (BPD) was investigated. BPD patients (n = 16) were compared to cluster-C personality disorder patients (n = 12) and to normal controls (n = 15). All subjects were female and diagnosed with SCID-I and -II. Subjects rated a short version of the Personality Disorder Beliefs Questionnaire (PDBQ), with six sets of 20 assumptions each, hypothesized to be characteristic of avoidant, dependent, obsessive-compulsive, paranoid, histrionic and borderline personality disorder. The BPD assumptions (Cronbach alpha = 0.95) proved to be the most specific to BPD patients. Subjects rated the shortened PDBQ again after viewing an emotional video fragment one week later. Despite increased negative emotions, the PDBQ ratings remained relatively stable. Confirming the cognitive hypothesis, regression analyses indicated that the BPD assumptions mediate the relationship between self-reported etiological factors from childhood (sexual abuse and emotional/physical abuse) and BPD pathology assessed with the SCID-II. It is suggested that a set of assumptions is characteristic of BPD, and is relatively stable despite the instability of the behaviour of people diagnosed as having BPD.

Patient-informant concordance on the Structured Clinical Interview for DSM-III-R personality disorders (SCID-II).

In the assessment of personality disorders, patients reports can be questioned for several reasons, such as lack of insight, shame, and acute psychiatric state. High concordance between patient-based and informant-based diagnoses would be an indication of the validity of patient reports (convergent validity). The present study examined the concordance between 42 psychotherapy outpatients and their informants (intimates) on the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II). Similar to prior studies, low or only modest levels of agreement were found. In comparison with evaluations of the personality of the patient by the therapist, patient interviews seemed to be more valid than informant interviews. Furthermore, couples with high intensity and intimacy in the contact generally showed higher agreement than couples with low intensity and intimacy. In conclusion, the data slightly suggest that patient reports are more valid than informant reports. However, the lack of a golden standard forces us to find more evidence before concluding that patient reports on personality result in valid diagnoses.

Short-interval test-retest interrater reliability of the Structured Clinical Interview for DSM-III-R personality disorders (SCID-II) in outpatients.

The short-interval test-retest interrater reliability of the Structured Clinical Interview for DSM-III-R personality disorders (SCID-II) was studied in a psychotherapy outpatient group whose main complaint was mostly an Axis I anxiety disorder. Using a test-retest approach to assess interrater reliability, three sources of variance were taken into account (rater variance in the elicitation and interpretation of information and patient variance across interviews). Base rate requirements were established before calculating reliability coefficients. On the whole, interrater agreement on the SCID-II was found to be satisfactory, except for the histrionic personality traits. This is the first study that has estimated short-interval test-retest interrater reliability of the SCID-II in outpatients, and also the first that has studied single SCID-II traits and dimensional diagnoses. The results found support the use of the SCID-II as a diagnostic instrument for clinical and research purposes.

The impact of personality disorders on treatment outcome of anxiety disorders: best-evidence synthesis.

Thirty-five studies were traced addressing the impact of comorbid personality disorders on treatment outcome of anxiety disorders. The conclusions of this review are based on the best-evidence procedure. We used two selection criteria that studies had to meet to be included in the present review. The study design had to be prospective and a (semi)structured interview had to be used for the assessment of personality disorders. From the fifteen selected studies it cannot be concluded that, in general, personality disorders affect treatment outcome for anxiety disorders negatively. We can only suspect that some personality disorders may have an adverse impact upon treatment outcome in anxiety disorders, and they should be investigated further. For the time being, in clinical practice one has to be cautious in relating personality disorders to less well treatment outcome in axis I anxiety disorders.

Personality disorders do not influence the results of cognitive and behavior therapy for obsessive compulsive disorder.

This study examined whether categorical or dimensional personality disorder variables affected treatment outcome in a sample of 52 patients with obsessive compulsive disorder who followed a standardized cognitive behavior therapy program. Treatment consisted of 12 weekly sessions and was completed by 43 patients. The Structured Clinical Interview for DSM-III-R personality disorders (SCID-II) was taken before the start of treatment by an independent rater. The treatment outcome measures included questionnaires and a Behavioral Assessment Test. Measurements were taken before and after treatment, and at 1 and 6 month follow-up tests. After the first follow-up test, further treatment was provided if clinically indicated. Neither categorical, nor dimensional personality disorder variables affected treatment outcome significantly. The inclusion of drop-outs in the analyses, did not change these results. Therefore, patients with obsessive compulsive disorder and concomitant personality disorder pathology should not be excluded from cognitive or behavior therapy for their obsessive compulsive complaints. Attributing therapy failure to concomitant Axis II pathology should be approached with caution.

Personality disorders do not influence the results of cognitive behavior therapies for anxiety disorders.

Two studies are presented in which the presence of personality disorders (PDs) was assessed using a structured clinical interview (Structured Clinical Interview for DSM-III-R Personality Disorders [SCID-II] by an independent rater before the start of treatment. The therapy effect was measured by change scores. In the first study, patients (N = 31) with panic disorder (with or without agoraphobia) received standardized cognitive behavioral treatment protocols. The effect of treatment as assessed by questionnaires and panic frequency was comparable in the groups with and without PD. In a second study, patients (N = 57) with various anxiety disorders were assessed before and after an individually tailored cognitive behavioral treatment. In general, results showed that anxiety patients with PDs have more severe axis I pathology, but show a change parallel to the patients without PD. Thus, if the effect of therapy is measured by change scores, PD is not related to therapeutic failure of cognitive behavioral treatment of anxiety disorders in general and panic disorder in particular.

Attention, not anxiety, influences pain.

Four hypotheses about the influences of anxiety and attention on pain impact were tested in a critical experiment: (1) anxiety increases pain; (2) anxiety decreases pain; (3) attention to pain increases pain; (4) only the combination of anxiety and attention to pain increases pain (interaction hypothesis). In a 2 x 2 design, anxiety (low vs high) and attention (attention vs distraction from the pain) were experimentally manipulated. Subjects received 20 electrically produced painful stimuli. Subjective pain experiences, skin conductance responses and heart rate responses gave no support for a pain impact increasing effect of anxiety. The anxiety-attention interaction hypothesis did not receive any support either. There was some support, only from the heart rate responses, that anxiety reduces pain impact. The critical factor appeared to be attention. Attention to the pain stimulus was related to a stronger pain impact (indicated by all measures) and to less subjective habituation, compared to distraction.