Detecting personality disorders in a nonclinical population. Application of a 2-stage procedure for case identification.

BACKGROUND: There is no epidemiology of personality disorders (PDs) comparable with that currently available for most other mental disorders. One reason for this is that an Axis II diagnosis usually requires considerable clinical sophistication and it is expensive to deploy clinicians rather than trained laypersons to examine large community samples. This study explores the feasibility of using a 2-stage method in which only subjects who were screened as positive for PD would be interviewed by clinicians. METHODS: University students were screened with a self-administered Axis II inventory and subsequently interviewed by clinicians with the use of the International Personality Disorder Examination. RESULTS: The screen detected all individuals who subsequently received a definite diagnosis on the interview, and a specificity rate of detection was 61%. The point-prevalence estimate for diagnosable PD in this nonclinical population was 11.01% (95% confidence interval, 7.57%-14.52%). CONCLUSION: If these results can be replicated in a more representative community sample, this 2-stage method might substantially reduce the number of persons who needed to be interviewed in a major epidemiological study of PDs, with little or no loss in diagnostic accuracy, while presumably lowering the cost of such an investigation.

Dependent personality disorder. Age, sex, and axis I comorbidity.

In the present report, we analyzed the age, sex, and axis I comorbidity of a large sample of patients with dependent personality disorder, and compared the findings with those obtained in patients with other personality disorders. The sample consisted of 3640 consecutive hospital admissions with a DSM-III axis II diagnosis. Of the 342 patients with a dependent diagnosis, 51.2% were over 40 years of age, compared with only 25.7% of the remaining patients with a personality disorder. The dependent sample was 69.6% female compared with 58.6% of those with other types of personality disorders. In general, dependent patients were more likely to have major depression and bipolar disorder than those with other personality disorders. Dysthymia and anxiety disorders occurred no more often than they did in the other personality disorders, as a whole. The rate of alcohol use disorders was lower than that observed in any other personality disorder except schizotypal. The rate of drug use disorders was intermediate between the lowest and highest rates in the other personality disorders.

The International Personality Disorder Examination. The World Health Organization/Alcohol, Drug Abuse, and Mental Health Administration international pilot study of personality disorders.

BACKGROUND: One of the aims of the World Health Organization/Alcohol, Drug Abuse, and Mental Health Administration joint program on psychiatric diagnosis and classification is the development and standardization of diagnostic assessment instruments for use in clinical research worldwide. The International Personality Disorder Examination (IPDE) is a semistructured clinical interview compatible with the International Classification of Diseases, Tenth Revision, and the DMS-III-R classification systems. This is the first report of the results of a field trial to investigate the feasibility of using the IPDE to assess personality disorders worldwide. METHODS: The IPDE was administered by 58 psychiatrists and clinical psychologists to 716 patients enrolled in clinical facilities at 14 participating centers in 11 countries in North America, Europe, Africa, and Asia. To determine interrater reliability, 141 of the IPDEs (20%) were independently rated by a silent observer. To determine temporal stability, 243 patients (34%) were reexamined after an average interval of 6 months. RESULTS: The IPDE proved acceptable to clinicians and demonstrated an interrater reliability and temporal stability roughly similar to instruments used to diagnose the psychoses, mood, anxiety, and substance use disorders. CONCLUSION: It is possible to assess personality disorders with reasonably good reliability in different nations, languages, and cultures using a semistructured clinical interview that experienced clinicians find relevant, meaningful, and user-friendly.

Trait-state artifacts and the diagnosis of personality disorders.

The multiaxial nature of DSM-III has stimulated interest in the personality disorders. There are also indications that it has produced an increase in their diagnosis. However, there is clinical and psychometric evidence that a personality evaluation undertaken while a patient is in a dysphoric mental state may distort or misrepresent traits, the so-called trait-state problem in personality assessment. The present study appears to be the first to investigate this phenomenon with a clinical interview rather than with personality tests. It examined the effect of anxiety, depression, and level of global impairment on the diagnosis of personality disorder and the assessment of the criteria for the individual Axis II disorders. Eighty-four patients, most of whom had current Axis I diagnoses, were evaluated by seven experienced clinicians with a new semistructured interview, the Personality Disorder Examination. The sample evidenced a trend toward acknowledging fewer maladaptive personality traits at follow-up than at entry. There was no evidence, however, that anxiety or depression had affected either the diagnosis of a personality disorder or the criteria associated with most of the individual personality disorders.

The impact of DSM-III on diagnostic practice in a university hospital. A comparison of DSM-II and DSM-III in 10,914 patients.

The DSM-III is the first criteria-based, multiaxial classification system of mental disorders. Since its introduction in 1980, it has received more attention than any previous nosology in the history of psychiatry. The present report attempts to gauge the impact of DSM-III on diagnostic practice at one of the largest university-affiliated psychiatric hospitals in the United States. It compares the diagnoses given to 10,914 hospitalized patients during the last 5 years of the DSM-II era and the first 5 years of the DSM-III era. There were two major consequences of the change from DSM-II to DSM-III: (1) a marked reduction in the diagnosis of schizophrenia and a corresponding increase in the diagnosis of affective disorders, and (2) a marked increase in the diagnosis of personality disorders.

DSM-III-R personality disorders in patients with eating disorders.

The authors conducted a systematic examination of DSM-III-R personality disorders among 35 patients with eating disorders. Fifty-seven percent of the patients met the criteria for at least one axis II diagnosis; borderline, self-defeating, and avoidant were the most frequently assigned personality disorders. Forty percent of the patients were given two or more diagnoses, and 17% of the patients met criteria for five to seven diagnoses. No differences were found between patients with anorexia nervosa, anorexia and bulimia nervosa, and bulimia nervosa in the distribution of diagnoses or the frequency with which individual criteria (traits) were assigned.

Detection of familial schizophrenia using a psychometric measure of schizotypy.

This study examined the lifetime expectancy (morbid risk) of schizophrenia, unipolar depression, and bipolar disorder in the first-degree relatives of 101 nonpsychotic psychiatric patients (probands) who were classified as schizotypy-positive or schizotypy-negative using a psychometric measure of schizotypy, the Perceptual Aberration Scale. The relatives of schizotypy-positive probands were significantly more likely to have been treated for schizophrenia than the relatives of schizotypy-negative probands. Morbid risk for unipolar depression or bipolar disorder among first-degree relatives did not differ between the proband groups. The results support Meehl's theory of the pathogenesis of schizophrenia and enhance the construct validity of the Perceptual Aberration Scale. The heuristic potential of a psychometric high-risk strategy in schizophrenia research is discussed and the need for replication of the present study is emphasized.

Psychosis proneness and clinical psychopathology: examination of the correlates of schizotypy.

The present report examined the associations between the Perceptual Aberration Scale (PAS), a prominent psychometric index of hypothetical psychosis proneness, and several measures of clinical psychopathology in a nonpsychotic psychiatric sample (N = 101). Patients were examined by experienced clinicians using structured psychiatric interviews to assess DSM-III-R Axis I and II conditions and rated for anxiety, depression, severity of illness, and current adult social competence. Elevated scores on the PAS were most closely associated with anxiety and depression as well as schizotypal, schizoid, avoidant, and obsessive-compulsive personality disorder symptomatology. Hierarchical regression analysis identified schizotypal symptoms and anxiety as the two underlying psychopathological processes most useful in explaining variance in PAS scores. Results are interpreted as supporting both the clinical relevance and research utility of the PAS and enhancing the construct validity of Meehl's model of schizotypy.

Family history of alcoholism in borderline personality disorder.

The lifetime expectancy (morbid risk) of alcoholism was determined in the parents and siblings of 83 women with DSM-III borderline personality disorder and compared with that in the parents and siblings of 100 women with DSM-III schizophrenia and 100 women with DSM-III bipolar disorder. The relatives of the borderline probands had two to three times more alcoholism than the relatives of the bipolar and schizophrenic probands. The condition was most common in the fathers of the borderline probands, almost one third of whom were either alcoholics or heavy drinkers. When the three groups of probands were subdivided according to whether they, themselves, had occasionally abused alcohol, there were no longer any significant differences in alcoholism among their relatives.

Structured interviews and borderline personality disorder.

A study was designed to determine whether the Diagnostic Interview for Borderlines (DIB) might be scored from the Schedule for Affective Disorders and Schizophrenia (SADS), and also whether DIB scores predicted the clinical diagnosis of DSM-III borderline personality disorder. One pair of clinicians interviewed patients with the DIB, and another pair interviewed the same patients with a slightly modified version of the SADS. Both interviews diagnosed virtually the same patients as borderline according to the criteria of Gunderson and Singer. The sensitivity of DIB scores in predicting a DSM-III diagnosis of borderline was 70%, while the specificity was 90%; the intraclass correlation coefficient was .75. Although there is a substantial concordance, the disparity between the DSM-III and DIB systems of diagnosing borderline patients is sufficiently great to preclude the generalization of findings from studies employing one set of criteria to those employing the other.

Sex difference in age at onset of schizophrenia.

The age at onset of schizophrenia was determined in 100 male and 100 female patients who unequivocally met DSM-III criteria for the illness. Three different indexes of onset were used: first treatment, first hospitalization, and the immediate family's first awareness of psychotic symptoms and signs. The mean age at onset of the male patients was approximately five years earlier than that of the female patients according to all three criteria. About nine of ten male patients, compared with only two of three female patients, became schizophrenic before the age of 30 years. The onset of psychosis after the age of 35 years occurred in 17% of women and in only 2% of men. About 10% of women gave no evidence of psychosis until after the age of 40 years. The reason for the sex difference is not readily apparent, but it could be a valuable clue to some of the causes of schizophrenia.

Familial transmission of DSM-III borderline personality disorder.

A comparison was made of the types of mental disorders occurring in the first-degree relatives of 83 female patients with DSM-III borderline personality disorder, 100 female patients with DSM-III schizophrenia, and 100 female patients with DSM-III bipolar disorder. Diagnosis of the relatives was made independently by two clinicians who were blind to the diagnosis of the probands. The relative of a borderline patient was about ten times more likely to have been treated for a borderline or borderlinelike personality disorder than was the relative of a schizophrenic or bipolar patient. The borderline patients' relatives were also treated for more unipolar depression than the schizophrenics' relatives. However, the relatives of the borderline patients did not have a higher morbid risk for treated mania or schizophrenia than that usually reported for the population at large.

Genetic independence of manic-depression and schizophrenia.

Increasingly sophisticated twin and adoption research has demonstrated major genetic contributions to the etiology of manic-depression and schizophrenia. But studies disagree concerning whether the two are genetically related illnesses. This lack of consensus could be due to individual, regional, and temporal differences in the criteria used to diagnose the two conditions. This study is the first to employ the new DSM-III criteria. Schizophrenia was no more common in the 1,098 first-degree relatives of 100 male and 100 female manic-depressives than it is in the population at-large. This would appear to strengthen the view that manic-depression and schizophrenia are genetically unrelated diseases.

Age at onset of bipolar affective illness.

The age at onset of bipolar affective illness was determined for 100 males and 100 females who met the newly proposed DSM-III criteria for mania. Three different indices of onset were employed: first hospitalization, first treatment, and first apparent symptoms. A table was constructed indicating the cumulative percentage of those who became ill by the time they passed through each age quinquennium. One third were hospitalized before their 25th birthday, and at least 20% had already shown evidence of illness as adolescents. The early 20s was the peak period of onset. No manic episodes were confirmed prior to age 13, and onset after age 60 was rare. Sex, ethnicity, and socioeconomic status did not significantly affect age at onset. Affective illness should be given serious consideration in the differential diagnosis of mental disorders in young people.

Mental symptoms in Parkinson's disease during chronic treatment with levodopa.

Mental symptoms increased in frequency among 100 patients with parkinsonism treated with levodopa. Dementia was found in about one-third of patients throughout the 6-year treatment period. Thirteen patients became demented during the study, and dementia worsened severely in seven others. Agitated confusion became increasingly frequent and was observed in 60 percent of patients taking levodopa for 6 years. Withdrawal from levodopa decreased agitation, but not dementia. Ten patients received L-tryptophan along with levodopa, but no change in mentation was observed. In view of previous studies of mentation in Parkinson's disease and reports of widespread neuronal changes in the brain of autopsied patients with parkinsonism, our results suggest that the high incidence of dementia in patients with Parkinson's disease who take levodopa reflects prolongation of the course of the illness rather than a direct effect of the medication.

X-linkage and manic-depressive illness.

Thirty years ago it was suggested that the apparently higher incidence of manic-depressive illness in women might be due to X-linked heredity. The hypothesis was undermined by subsequent reports of the frequent occurrence of father to son transmission. Winokur and his associates recently revived it, providing data which indicated that such transmission is absent or rare in the bipolar form of the illness. Additional support has come from linkage studies with known genetic markers located on the X chromosome. The present study, based on the 400 parents of 100 male and 100 female bipolar manic-depressive probands, failed to discover a lack of father-son compared to other affected parent-child pairs. This finding, together with a review of the literature, would indicate that it is premature to invoke X-linked heredity as a general explanation for bipolar manic-depressive illness, though there is mounting evidence that it may account for the illness in some family pedigrees.